On some of the mental affections of childhood and youth; being the Lettsomian lectures delivered before the Medical society of London in 1887, together with other papers

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MENTAL AFFECTIONS

CHILDHOOD AND YOUTH

ON SOME OF THE

MENTAL AFFECTIONS

CHILDHOOD AND YOUTH

THE LETTSOMIAN LECTURES

DELIVERED BEFORE THE MEDICAL SOCIETY OF LONDON
IN 1887

TOGETHER WITH OTHER PAPERS

J. LANGDON DOWN, M.D.Lond.

riLLOW OF THE EOYAL COLLKGE OF PHYSICIANS OP LONDON; SENIOR PHYSICIAN TO, AND

LBCTUKKE ON CLINICAL MEDICINE AT, THE LONDON HOSPITAL ; FOKMEKLY LECTUEER

ON MEDICINE, MATERIA MEDICA, AND COMPAEATIVE ANATOMY AT THE LONDON

HOSPITAL; AND PHYSICIAN TO THE EAELSWOOD ASYLUM

LONDON
J. & A. CHURCHILL

11, NEW BURLINGTON STREET

1887

Digitized by the Internet Archive

in 2010 with funding from

Open Knowledge Commons

http://www.archive.org/details/onsomeofmentalafOOdown

PEEFACE

When the Medical Society of London
honoured me with the request to pubhsh
these Lectures, I felt, in complying with the
wish so kindly expressed, that I should add
to the value of the contribution by reprinting
fugitive papers relating to the same subject,
to some of which I have referred in the
Lectures themselves. These papers I have
printed in chronological order as the most
convenient form.

J. LANGDON DOWN.

81, Harley Street, W. ;

May, 1887.

CONTENTS

MENTAL AFFECTIONS OF CHILDHOOD
AND YOUTH.

LECTURE I.

PAfiES

History of the Subject. — Nomenclature. — Ethnic 01a;8-
sification. — Etiological Classification. — Physioal
Characteristics. — Intellectual Characteristics 1—42

LECTURE II.

Causes of Idiocy. — Accidental Origin. — Developmental
Origin. — Congenital Origin. — Influence of Maternal
Health ; of Alcoholism ; of Malignant Disease and
Syphilis; of Neurotic or Phthisical Inheritance;
of Trades and Professions; of Marriages of Con-
sanguinity ; of Illegitimacy ; Idiocy from Depriva-
tion of Senses; Cretinism; Influence of "Over-
Education " of Women . . . 43—90

LECTURE III.

Infantile Mania. — Melancholia and Delueions. — Moral
Insanity. — " Idiots Savants." — Yariations in the
Mental Condition. — Epilepsy and Catalepsy. — Phy-
sical Deformities. — Associated Diseases. — Rate of
Growth. — Diagnosis of Idiocy. — *' Backward Child-
ren."—Deferred or Absent Speech. — Morbid Ana-
tomy.— Treatment of Feeble-mindedness . 91 — 142

Vlll CONTENTS.

PAGES
Account of a Case in which the Corpus Callosum and
Fornix were imperfectly formed and the Septum
Lucidum and Commissura were Absent . 143 — 153

On the Condition of the Mouth in Idiocy . 154 — 166

On Polysarcia and its Treatment . . 167 — 180

An Account of a Second Case in which the Corpus

Callosum was defective . . . 181—184

Marriages of Consanguinity in relation to Degenera-
tion of Race .... 185—209

Observations on an Ethnic Classification of Idiots 210 — 217

On Idiocy and its Relation to Tuberculosis . 218 — 230

A Case of Asymmetrically Developed Brain . 231 — 235

A Case of Microcephalic Skull . . . 236—238

A Case of Microcephalic Skull . . . 239—241

A Case of Arrested Development . . 242 — 244

A Case of Paralysis with apparent Muscular Hyper-
trophy ..... 245—^6

A Case of Pseudo-hypertrophic Paralysis . 257 — 267

On the Relation of the Teeth and Mouth to Mental

Development . . . 268—288

The Obstetrical Aspects of Idiocy . 289—307

MENTAL AFFECTIONS OF CHILDHOOD
AND YOUTH.

LECTURE I.

History of the Subject. — Nomenclature. — Ethnic Classification.
— Etiological Classification. — Physical Characteristics. —
Intellectual Characteristics.

When you, sir, and your colleagues on the
Council of the Medical Society of London, did
me the honour to request me to deliver the
Lettsomian Lectures on Medicine for this year,
I bethought myself that mental deviations in
childhood and youth had never been the subject
of a disquisition from this chair, and that pro-
bably a period of nearly thirty years spent
among children with various phases of mental
affection might entitle me to bring before the
members of this Society material which, from
the nature of the subject, can only be accumu-
lated by a few.

There is not much to be found on this subject
in the early records of medicine. Children who
were afflicted by mental aUenation or mental

1

MENTAL AFFECTIONS OF

incapacity of any kind were placed in tlie cate-
gory of idiots and regarded as beyond tlie pale
of help. Formerly no attempt was made to
ameliorate their condition, and a Spartan-like
policy was rife, which troubled itself only with
the survival of the fittest. It has been reserved
for the medicine of modern times to occupy itself
about the waifs of humanity who come under
the category of the feeble in mind. The earliest
attempts at the education of idiots took place in
France some years since, but they were at first
isolated efforts under the direction of M. Seguin
at the Bicetre. It was, however, in 1842 that
attention was more particularly directed to the
subject by the establishment of a school on the
Abendberg, in Switzerland, which was opened
by Dr. Guggenbiihl, who entered on his work
with true enthusiasm, — an enthusiasm which one
regrets was quenched by the flattery of English
drawing-rooms. I shall never forget the feel-
ings of disappointment and chagrin when, on
reaching the summit of the Abendberg, which
I had mounted as a pilgrim to a shrine, I found
the pupils in a state of physical and mental
neglect while the patron saint was being ener-
vated by the Capua-like influence of the West

CHILDHOOD AND YOUTH.

End of London. Fortunately for the pupils the
Commune stepped in and closed what had
become a parody on philanthropic effort.

About the same time M. Saegert, at Berlin,
who had been engaged in the instruction of
deaf mutes, extended his efforts for the benefit
of a class whose mutism was not the outcome
of deafness. His school is still carried on with
much skill in the neighbourhood of Berlin, but
with the immense disadvantage of being located
in, and associated with, a large lunatic asylum.
On a recent visit which I paid it I found excel-
lent work was being done there although handi-
capped by the association to which I have
referred. It was in the year 1846 that a general
movement took place in efforts for ameliorating
this afflicted class. Germany took the lead by
the establishment of a school at Leipzig. Dis-
cussions in the periodical press were initiated
by Mrs. Plumbe, of London, whose personal
interest in the matter forced the subject on the
attention of such philanthropists as Dr. Conolly
and Dr. Andrew Reed. Synchronously, public
attention was being given to the subject in the
United States of America, where, while poli-
ticians were delaying action in the matter, the

MENTAL AFFECTIONS OF

private enterprise of tlae late Dr. Wilbur brought
it to a practical issue. England meanwhile
commenced the work by the establishment of a
small school at Bath. It was not, however,
till 1847 that the great effort was made which
resulted in starting a small institution at High-
gate in 1848 and subsequently another at
Colchester. These grew into the large institution
at Earlswood, of which in 1858, at tbe mingling
of the inmates from these homes at Highgate and
Colchester, I undertook the superintendence.
In recent years other institutions have been
created both in England, Ireland, Scotland, the
United States, and on the Continent of Europe.
Schools have been established at Darenth for
the feeble-minded paupers of London. One
hopes that the time may not be far distant when
suitable provision may lie within the reach of
the afBicted poor who live beyond the metro-
politan area.

It is not uncommon to class all cases of
mental lesion occurring in the young under the
category of idiocy, or to speak of those ajQBicted
with the graver forms of the malady as idiots,
while the subjects of the milder or less grave
manifestations are called imbeciles. This no-

CHILDHOOD AND YOUTH.

menclature is open to grave objection. The
term imbecile is very often applied to that class
of mental infirmity which is the outcome of
deteriorating organic causes, often senile. Men
or women who may have been in their time
capable citizens become the subjects of senile
changes of nutrition and lapse into a condition
of childishness. It is people of this class who
are rightly termed imbeciles, and to whom in my
opinion the designation should be thoroughly
restricted. I know of no defining limitation be-
tween so-called idiocy and so-called imbecility.
The gradations of mental incapacity are as nu-
merous and delicate as are those of mental capa-
city among those who are doing the world's work.
The division, therefore, into imbeciles and idiots
is thoroughly wrong and misleading. I have
no great liking for the term idiot. It is so fre-
quently a name of reproach. Moreover, in most
cases it does not fairly represent the conditions
which exist. The word idiot means " solitary,"
and the typical idiot knows nothing, sees nothing,
does nothing, and this typical idiot is scarcely
ever met with except in anencephalous monsters.
This objection to the term idiot is not a mere
sentimental one on my part. No one likes the

6 MENTAL AFFECTIONS OF

name, and no mother will admit that her child
deserves the title. The constant introduction
of a case from medical men is, " I send you a
little child for your opinion, but it is not an
idiot ;" or the mother brings her child to one,
saying, " I have come to consult you about my
boy, but he is not an idiot." This is the regular
formula. A great impediment is thereby intro-
duced to the early appreciation of the lesion
and to its early treatment. The term idiot
might be advantageously replaced by that of
feeble-minded, idiocy being in fact mental
feebleness depending on malnutrition or disease
of the nervous centres taking place anterior to
birth or during the developmental years of
childhood and youth. Idiocy is therefore readily
differentiated from other forms of mental alie-
nation. The term imbecile should be applied
to the cases of dementia which crowd our lunatic
asylums and who are in an entirely different
category from the feeble-minded; they are
gradually deteriorating in physical, mental, and
moral condition ; they are in the position of
spendthrifts who have dissipated their fortune,
while idiots for the most part have never entered
on a fortune to dissipate.

CHILDHOOD AND YOUTH.

Some years since I was struck by the remark-
able resemblance of feeble-minded children to
the various ethnic types of the human family,
and showed, in a paper which I contributed to
the ' London Hospital Reports ' in 1866, in how
many instances one could refer them to one or
other of the ethnological families. I have had
under my care typical examples of the negroid
family, with characteristic malar bones, the
prominent eyes, the pufiy lips and retreating
chin. They have had the woolly hair, although
not black, nor has the skin acquired pigmentary
deposit. They have been examples of white
negroes, but of European descent. Several,
again, have arranged themselves around the
Malay variety, with soft, black, curly hair, pro-
minent upper jaws and capacious mouths, types
of the South Sea Islands. I have also met with
a few instances of the North American Indian
type, with shortened forehead, prominent cheeks,
deep-set eyes and slightly apish nose. A con-
siderable number range themselves under the
Mongolian type. More than 10 per cent, of
congenital, feeble-minded children are typical
Mongols. They present characteristics so
marked that when the members of this type are

8 MENTAL AFFECTIONS OF

placed in proximity it is diflScult to believe
that they are not brothers and sisters. In fact
their resemblance is infinitely greater to one
another than to the members of their own
families. They rarely have black hair, as in the
real Mongol, bnt it is of a brownish colour,
straight and sparse. The face is flat and broad
and destitute of prominence. The cheeks are
roundish and widened laterally. The eyes are
obliquely placed and the internal canthi more
than normally separated. The palpebral fissure
is very narrow, the forehead is wrinkled trans-
versely from the constant use of the occipito-
frontalis muscle in opening the eyes. The lips
are large and thick, with transverse fissures.
The tongue is long and thick and very rugous.
The nose is small. The skin has a tawny colour,
and is deficient in elasticity, giving on the hands
the appearance of being larger than is necessary.
The ethnic classification of idiocy which I
indicated is of extreme interest philosophically
as well as of value practically. Philosophically
because it throws light on a question which
very much agitated public opinion about the
time of the American Civil "War. The work of
Nott and Gliddon laboured to prove that the

CHILDHOOD AND YOUTH. 9

various ethnic families were distinct species,
and a strong argument was based on this to
justify a certain domestic institution. If, how-
ever, it can be shown that from some dete-
riorating influence the children of Caucasian
parents can be removed into another ethnic
type, it is a strong corroborative argument that
the difference is a variable and not a specific
one. The classification is also a practical one.
We are able to say, with the greatest possible
certainty, that the members of these ethnic
types date the origin of their mental feebleness
to congenital causes.

It is often of great importance to determine
the question as to whether the affliction has had
an accidental beginning. The medical attendant
may be charged with malpraxis. The nurse
may be suspected of having allowed the infant
to fall or of having drugged it with opiates.
The being able to refer the child to an ethnic
type other than Caucasian settles beyond ques-
tion that the cause of the malady, whatever it
may be, was antecedent to birth. Again and
again has this process of reasoning come to my
assistance in determining questions of the
gravest possible import, and enabled me to

10 MENTAL AFFECTIONS OF

assure anxious friends tliat innocent people
have been unjustly blamed. Not only so, by a
recognition of type we are able to determine
the physical as well as mental and moral charac-
teristics of the child in a way which astonishes
the mother, who finds one is able to anticipate
all she has to relate. This is especially the
case with the Mongolian type, the numerous
instances of which coming under one's notice
enables one to become familiar with its leading
characteristics. These children have always
great power of imitation and become extremely
good mimics. Several patients who have been
under my care have been wont to convert their
pillow-slips into surplices and to imitate, in tone
and gesture, the clergyman or chaplain they
have recently heard. Their power of imitation
is moreover not limited to things clerical. I
have known a ventriloquist to be convulsed
with laughter between the first and second
parts of his entertainment on seeing a Mongolian
patient mount the platform, and hearing him
grotesquely imitate the performance with which
the audience had been entertained. They
have a strong sense of the ridiculous ; this is
indicated by their humorous remarks and the

CHILDHOOD AND YOUTH. 11

laughter with which they hail accidental falls,
even of those to whom they are most attached.
Another feature is their great obstinacy, — they
can only be guided by consummate tact. No
amount of coercion will induce them to do that
which they have made up their minds not to
do. Sometimes they initiate a struggle for
mastery, and the day previous will determine
what they will or will not do on the next day.
Often they will talk to themselves, and they may
be heard rehearsing the disputes which they
think will be the feature of the following day.
They in fact, go through a play in which the
patient, doctor, governess, and nurses are the
dramatis personas, — a play in which the patient
is represented as defying and contravening the
wishes of those in authority. Whether it be
the question of going to church, to school, or
for a walk, discretion will often be the better
part of valour, by not giving orders which will
run counter to the intended disobedience, and
thus maintaining the appearance of authority
while being virtually beaten. They are always
amiable both to their companions and to animals.
They are not passionate nor strongly affection-
ate. They are usually able to be taught to

12 MENTAL AFFECTIONS OF

speak ; the speech, however, is somewhat thick
and indistinct, and destitute of musical cadence.
The co-ordinating faculty is abnormal, but may
be greatly improved by training. The circula-
tion is usually feeble, and whatever advance is
made intellectually in the summer some amount
of retrogression may be expected in the winter.
They undergo, in fact, a species of hibernation ;
not only are they prone to chilblains and frost-
bite, they are but little tolerant of excessive
heat, and proximity to a fire which to many
would be only agreeable would, to patients of
this class, be attended by serious blistering of
the legs, even when protected by stockings or
other articles of clothing. The resemblance to
one another is so great in members of this
family, both in their physical, moral, and
intellectual natures, that the probability was
forced on one that there was some unity
of cause for their malady. Further investi-
gation pointed out that phthisis was very fre-
quently met with in the history of their pro-
genitors. It is noticeable also that these
children have not a long career, very few
reaching adult life, being prone to succumb to
serious illness or to become phthisical like their

CHILDHOOD AND YOUTH. 13

ancestors. Their crania have a marked simi-
larity, they are all brachycephalic and the pos-
terior part is ill-developed.

Latterly I have been accustomed to adopt a
classification based on the etiology of the cases.
This is valuable from its practical bearing, and
because it brings into prominence a class which
was formerly not considered, or at all events
had not the attention given to it which it
merited.

It was very early presented to my notice that
a large number of feeble-minded children were
capable of being referred to one or other of two
great groups — the one where there was a com-
plete history of the congenital origin of the
malady, with the physical proofs, which I shall
presently refer to, and the other where it was
no less clear that the asseverations of the
mother that her child was born with ordinary
intelligence was quite correct, but that some
accident or some extension of disease equiva-
lent to an accident had wrought on the cerebral
centres disastrous changes, interfering with
intellectual manifestations. Parents always
prefer to refer the case to a post-uterine
or non-congenital origin, partly because they

14 MENTAL AFPEOTIONS OF

think it frees them from the suspicion of here-
ditary influence, and partly from a notion that
the child is more likely to be restored to
its pristine state. We have these two well-
defined classes : (1) The congenital, and (2)
the accidental. On investigating, however, a
large number of cases I became familiar with
many instances which it was impossible to
include in either of these categories. There
was no history of accident nor of any illness
akin to accident ; the examination, however
thorough, revealed nothing which would war-
rant the opinion that the origin was accidental.
There was, moreover, in these cases, no reason
to regard them as congenital. On the contrary,
all the historical evidence, as well as all the
physical evidence, positively refuted any such
idea.

Under what head, therefore, were they to be
placed ? I found that the history was some-
what of the following. Their early months
of babyhood were perfectly uneventful ; there
had been nothing to cause the slightest anxiety ;
intelligence had dawned in the accustomed way,
when, first dentition proceeding, a change had
come over the aspect of the child. Its look had

CHILDHOOD AND YOUTH. 15

lost its wonted brightness ; it took less notice
of those around it ; many of its movements
became rhythmical and automatic, and with or
without convulsions there was a cessation of
the increasing intelligence which had marked its
early career ; anxiety was felt on account of the
deferred speech, still more from the lessened
responsiveness to all the endearments of its
friends. In others the crisis at first dentition
is not so marked. Speech may be a little de-
ferred, but it comes, and with it more mental
power ; at second dentition, however, they are
prone to crises in which the intelligence be-
comes altered, they have night terrors, and not
unfrequently loss of speech. I have had many
examples of children who had spoken well and
with understanding, but who lost speech at the
period of second dentition, and had also a
suspension of mental growth.

I have now under my observation a boy who,
except that he was a little backward in speaking,
not talking till he was two years of age, attracted
no particular attention during the first six years
of his life. During the period of second dentition,
without any fit or convulsion, he suddenly lost
speech. He heard everything that was said,

16 MENTAL AFFECTIONS OF

but never replied to a question. He would
caress and coax, but never asked for what he
wanted. It was not a case of aphonia ; he
appeared to have no power to convert ideas into
words. He would cry peevishly if there was
something he wanted that he could not have.
This condition of things continued for eighteen
months, when, suspecting masturbation, he was
circumcised by Mr. Heath. Grradually, after
two years' absence, speech returned. He had
to be taught anew, first the names of objects, and
then to build up sentences until, at the end of
six months, my notebook says, " Speaks several
sentences voluntarily." However, he afterwards
always spoke of himself in the third person.
He is now passing through the evolutionary
period of puberty without any recurrence of the
loss of speech faculty, but he has never regained
active mental power. There is reason to regard
it as a case of developmental feeble-mindedness
resulting from illness of his mother at the
seventh month of pregnancy.

I have had under my care two brothers who
had spoken with discrimination and understood
well two languages, but who both lost speech
at the period of second dentition. As the

CHILDHOOD AND YOUTH. 17

elder one approached, that period, gradually,
without any paroxysmal event, he lost speech,
and when the younger one arrived at the
same age, gradually, but entirely, did he lose
speech also. It may be, however, that the
periods of first and second dentition are passed
harmlessly and the breakdown is reserved for
the time of puberty. Many at this time become
suspicious and reserved, some become hyper-
conscientious, are always practising a process
of introspection, are disturbed in their mind
lest they should not have rightly stated any
circumstance, or, if they have correctly stated
it, whether they have put the facts in such a
way as to have produced the right impression ;
many become epileptic, with rapid declension
of intellectual power. These cases have usually
characteristic crania ; they are dolichocephalic
and are prow-shaped anteriorly, — the line cor-
responding to the medio-frontal suture being
a prominent ridge. There is reason to believe
that in these cases there has been an arrest
of the synostosis of the medio-frontal suture
which should have taken place during intra-
uterine life, so that the lateral pressure on
the separated frontal bones determines, when

18 MENTAL AFFECTIONS OF

the deferred ossification takes place, a pro-
minence where there should have been a
plane or slightly concave surface between
the frontal eminences. In the great bulk of
these cases well-marked evidence can be obtained
of some disturbing cause towards the later
months of pregnancy, which has led to this con-
dition; and although the deferred synostosis and
its consequent deformity is of no consequence,
it is reasonable to believe that the same cause
which arrested the bony union has also arrested
the development of the cerebral centres and
rendered them more unstable. Certain it is
that children with such a conformation are
almost sure to break down at one or other of the
developmental epochs. Their nervous system
would appear to be equal to the requirements of
growth but not of development. They form
a class of cases which I have suggested
should be called the " Developmental," as con-
tradistinguished from the " Congenital " on the
one hand, and the " Accidental" on the other.
They are a very important class, because, fore-
warned, catastrophes may be avoided. They
are the cases which break down by over-excite-
ment in babyhood and by " over-pressure " in

CHILDHOOD AND YOUTH. 19

schools at second dentition and puberty. So
frequent is tlie association of this condition of
the cranium with neuroses that I have been
accustomed for many years to point this out to
my students at the London Hospital, and to
show them that the prow-shaped skull is an
outward and visible sign of an unstable nervous
system, not of itself a cause, but indicating, like
the seaweeds on the seashore, how far the tide
has come. The members of this class do not
give evidence of mental defect before their
breakdown ; they furnish, however, a number of
those who become petulant, wayward vagrants
from the elementary school, runaways from the
public school, sometimes interesting and with
flashes of precocious genius, they become the
subjects of headache under continuous intel-
lectual strain, a headache which, if not regarded,
leads on infallibly to disastrous neuroses or
developmental idiocy.

A large number of boys and girls come under
my notice who are not feeble-minded, who have
in a high degree the prow-sha]3ed forehead,
and who have their nervous system in such
an unstable equilibrium that the least intellectual
pressure at developmental epochs is attended

20 MENTAL AFFECTIONS OF

by disastrous results. They are brought to me
on account of severe frontal headache, or of
wayward petulance, or incapacity for sustained
mental exertion. I cannot better illustrate the
kind of case which so frequently comes under
my observation, and the serious character of
which it is of the first importance early and
clearly to recognise, than by quoting from the
letter of the mother of one such patient.
She says, " I have a boy eight and a half years
old who is continually suffering with headache
from temple to temple, and over the front half
of head. He is a child of fine physique, capable,
practical, clever, so far as the head permits of
lessons, which means but a short amount and
often missed altogether, for the same reason —
* headache,' — apparently the picture of health,
high spirits, active, bright, yet done up with so
little. The child is not a rickety creature —
more is the puzzle. We shall bring him to see
you on Tuesday next, and I think it better to
give you all particulars before our visit that
you may form an opinion on the whole. In the
Spring after a certain pressure of the usual
morning work, he would turn grey, gasp for
air, and, with windows all open, say he was

CHILDHOOD AND YOUTH. 21

choked. These attacks were frequent, and the
sensations in the throat seemed to frighten him
greatly. Lately I have heard less of this ; now
it seems ' head ' affecting him ' all over ' as he
expresses it.

" Since then he has grown tall and much
stronger, crickets fairly well, can handle any tool
' properly,' has good sense, good memory, a
bad or rather tempestuous temper, quickly over,
strong will, and ought to be a boy well to the
front ; but, alas for such hopes, there is ever a
something cropping up which knocks it all over.
Then fatigue, long journeys, lessons, and all is
depression and pain, and a heavy dulness of
power (never of intellect) which is heart-
grieving to me. Writing tires him, yet he
works his Latin sentences with ease aloud, only
two a day. Two hours' work has become half an
hour, sometimes lately five minutes. He remains
still over-full of life and go, at times, with no real
strength, irritable, open, upright, self-willed,
loving, very true, still all wrong, and why ?"

When the boy presented himself to me
he displayed a typical neurotic forehead, and
there was a very complete history of severe
emotional disturbance on the part of the mother

22 MENTAL AFFECTIONS OF

between the sixth and seventh month of preg-
nancy. I counselled complete abstention from
intellectual work during the remaining period of
second dentition. It was very clear to my mind
that any continued pressure would lead, through
convulsions, to developmental idiocy.

Dr. West has pointed out how stammering
never occurs among young childreu, and says,
" I never knew a child stammer before the
commencement of the second dentition." My
own experience would lead me to confirm the
observations of that distinguished physician,
and I would further say that I have never met
with a case of stammering at that period which
did not bear evidence of its being a develop-
mental neurosis, and that its origin could be
traced back to a period anterior to birth, to an
arrest of development which begat a proclivity
to nervous breakdown. In these cases the
approach of puberty is a period of grave
anxiety. It is at that time that masturbation
is so liable to lead to disastrous results, and that
epilepsy is so prone to occur. The nervous
system may have been stable through the
developmental periods of first and second
dentition and yet break down at the evolution

CHILDHOOD AND YOUTH. 23

of puberty, and there is much sagacity in Dr.
West's observation : " It is usually with the
evolution of the sexual system that hysteria
shows itself, and with the pressure of life's cares
that the mind is thrown off its balance, and
then it is with regard to both that the ancestral
taint first displays itself ; so too, is it, I believe,
to a great degree with the hereditary tendency
to epilepsy." It is, I would venture to say, the
influence of the neurotic mother on the embryo
during the later months of development that
begets the proclivity which is here referred to.
I have alluded already to a group which I
have ventured to describe as "accidental." I
wish thereby to refer to a class of cases which
differ from the " developmental " in the date of
the origin of their calamity. They are children
who are born, or ready to be born, with all the
potentiality of intelligence, but whose brain
becomes damaged by traumatic lesions, by medi-
cations, or by inflammatory disease. There is
this one character running through the class, — a
character on which I wish to lay as great stress
as I have on the prow-shaped cranium of the
developmental class, viz. the absence of any of
the physical aspects of f eeble-mindedness . They

24 MENTAL AFFECTIONS OP

are bright in their expression, often active in
their movements, agile to a degree, mobile in
their temperament, fearless as to danger, perse-
vering in mischief, petulant to have their own
v^ay. Their language is one of gesture only ;
living in a world of their own they are regard-
less of the ordinary circumstances around them,
and yield only to the counter-fascination of
music.

These are the cases in which mothers enter-
tain the strongest hope, and in which the doctor
endorses the hope with confidence based on
the pretty waywardness of the child. I cannot
enforce too strongly grave caution in the pro-
gnosis which should be given in such cases ;
they are the most disappointing which one is
called upon to treat. A period of nearly thirty
years has enabled me to study not only the
present but the future of such children, to make
a forecast, based on experience as to results,
and to correct the notions of sanguine hopeful-
ness. So interesting are they in appearance
that it is diflficult to realise that they will not
be perfectly responsive to training, and that
speech will not be speedily gained. I know
nothing more painful than the long motherly

CHILDHOOD AND YOUTH. 25

expectancy of speech. ; how, month after month,
the hopes are kept at high tension, waiting for
the prattle which never comes. How the self-
contained and self-absorbed little one cares not
to be entertained other than in his own dream-
land, and by automatic movements of his fingers
or rhythmical movements of his body. I
cannot recommend too strongly that caution
should be used in giving a hopeful prognosis
concerning children of this class. They have
well-formed heads, finely-textured skins, well-
chiselled mouths, sparkling eyes, features when
in repose leading one to augur only bright-
ness and intelligence. Surely, it may be
thought, the mind is ready to be developed
from such a casket, and time only is required
to ensure the thorough realisation of all one's
wishes. Opinions based on such a theory will
prove utterly fallacious. In these cases there
is no outward sign of mental vacuity, for
there has been nothing during the period of
intra-uterine life to arrest the evolutionary
stages, and stamp its impress on the bodily or
facial formation. The cause of the mental de-
ficiency has been something occurring during
post-ufcerine life, — some catastrophe notinherent

26 MENTAL AFFECTIONS OF

in the cliild, no hereditary taint to mar the
beauty of his visage or the grace of his cranial
contour ; yet there is something more potent
for evil than in the case of many a malformed
face and many a distorted skull. He runs to
you when called, but makes no response in
words. He returns your kiss by a bite, and
runs away with agile steps, rolling his head
with a horizontal swaying motion, or with
fingers in ears or at eyeballs producing distorted
sounds or double vision, and as he goes, rushing
to knock down objects in order to produce an
unharmonious noise. They are cases with a
vast amount of surplus nervous energy, and
although much may be done by training to
divert the energy into better channels, the im-
provement will be smaller than what may be ob-
tained from apparently less promising children,
because, as I have elsewhere said, there is more
improvement to be obtained from an ill-
developed than from a damaged brain.

The late Professor Griesinger, with whom I
have frequently had opportunities of discus-
sing this and kindred subjects, describes two
varieties of idiots — the apathetic and the ex-
cited. The apathetic class he describes as

CHILDHOOD AND YOUTH. 27

awkward, clumsy, and disproportioned, with
repulsive old-looking features. From their
torpor and impassiveness thej seem to be in a
dreamj state. Their expression is either brood-
ing and molancholj, or vacuous and indifferent.
The excited or agitated class he describes as
just as stupid as the other, but quick in
movement and irritable, passing rapidly from
one impression to another, and quite incapable
of fixing anything on their minds. I have no
doubt Griesinger had in view, in describing the
latter class, some of the accidental cases whose
manifestations I have been discussing. There
is no attempt, however, in this classification to
refer them to their cause, nor can I admit that
the division is true to nature or practically
useful.

Having thus discussed two of the great
classes, the accidental and the developmental,
there remains for me to describe the character-
istics of the remaining one, viz. the congenital.
This contains by far the largest number of
subjects, and presents characters which are
of great value in determining the origin and
future of its members. They are less in-
teresting in appearance but more amenable

28 MENTAL AFFECTIONS OF

to training, other things being equal, than
either of the other two classes, and especially
than the members of the accidental class. The
origin of their malady dates from earlier in
intra-uterine life than does that of the members
of the developmental class, and in many
cases the proclivity resides in the germ-cell or
sperm-cell, as the result of gradual degenera-
tion. That being so, it is not surprising that
members of this class should bear in their
bodily formation marks of physical change.
They for the most part have a tendency to fall
under one or other of the ethnic groups which I
referred to in the early part of this lecture.
Some years since I gave great attention to this
subject, and prepared much material for a
paper on the physical aspects of idiocy. A
great many descriptions had been written, by
no means precise, on the intellectual condition
of idiots, but none, so far as I know, on their
physical attributes. It is now several years
since that this city was excited by the trial
before a Master in Lunacy of a young man
whose ability to manage his affairs was doubted.
The author of ' Ten Thousand a Year ' presided
at the trial. Experts on both sides gave evi-

CHILDHOOD AND YOUTH. 29

dence on the psydaological condition. The late
Lord Cairns (then Sir Hugh) was the advocate
for the youth, and he argued strongly that the
error had been fallen into of supposing this
young man was feeble-minded because he had
a high arched palate, and in other ways a de-
formed mouth, so that his defective utterances
had given rise to the opinion that he was de-
ficient in mental power. From the material I
had collected I wrote a paper for the ' Lancet ' to
show that, granted any suspicion of defective
mental power, the deformation of the mouth,
with its vaulted palate, was the strongest corro-
borative proof, a proof too of the congenital
origin of his condition. My paper was too late
to enable the opposite side to call me, and it
could only be made use of in the opposing
counsel's final address. The jury supported
the doctrine of the liberty of the subject, and
the poor congenital imbecile was allowed to go
his own way to destruction, with the result of
becoming speedily bankrupt in fortune, ruined
in health, and a scandal to an honoured
ancestral name.

Still more recently, a youth on coming of age
sought to obtain possession of his property.

30 MENTAL AFFECTIONS OF

There was strong evidence brought as to his
conduct being incompatible with mental capa-
city, and the physical deviations were confirma-
tory of the congenital character of the feeble-
mindedness. The jury, however, decided by a
small majority that he was capable of managing
his own affairs, although they were equally
divided as to his mental soundness. Within
forty-eight hours he was in prison for gross
criminal conduct, and he speedily terminated a
career of infamy from want of legal protection,
which the poor feeble-minded youth could not
give to himself. In the cases I am describing
the cranium is usually smaller than normal,
dolichocephalic in many but brachycephalic in
the Mongolian type. Occasionally the head is
scaphocephalic, the line of the sagittal suture
giving a keel-like feature to what resembles an
inverted boat. A very common character is a
rapid shelving from the vertex posteriorly, cor-
responding to what is so frequently to be
noticed, an arrest of development of the occi-
pital lobe of the cerebrum. Not unfrequently
the cranium is extremely small, reverting to the
Aztec type. These examples of extreme micro-
cephalism have been attributed by Virchow to

CHILDHOOD AND YOUTH. 31

premature synostosis of the cranial sutures. I
have found, however, that in some of the most
marked members of the microcephalic group the
sutures are well marked and every indication
that the cranium had adapted itself to the cere-
brum rather than that the cerebral mass had
been dominated by the cranium. They are
cases in which the brain and bony covering are
both in miniature, the arrest having had an
early intra-uterine date. It would be a grave
error to imagine that there is an inverse rela-
tion between the size of the cranium- and the
intellectual capabilities of its possessor. I
have known children with the most complete
Aztec- like heads susceptible of some amount of
education ; they have been taught to talk, to
discriminate, to take a real pleasure in the
world around them, appreciate the jokes in a
dramatic entertainment, and play intelligently
with toys. I have under my care now one
who has been taught to speak with discrimi-
nation, to say the conventional thing, to play
on the piano simple airs, to read story books
with enjoyment, and to have a practical appre-
ciation of right and wrong. They are usually
mobile in temperament, sometimes very active

32 MENTAL AFFECTIONS OF

physically, and always tractable, amiable, and
appreciative of kindness. They illustrate the
fact that there is such a thing as quality in brain-
matter as well as quantity, and that the relative
intelligence among feeble-minded children can-
not be estimated simply by the tape and calipers.
Macrocephalic crania are not unfrequently met
with, some being due to hydrocephalus, and
others to an increase of the neuroglia of the
cerebral mass. I have had patients under my
care whose brains were within an ounce of the
weight of that of Ouvier, who, nevertheless, were
slow in their movements and slower in thought,
and were perfect contrasts in intellectual slug-
gishness to the volatile microcephalic Aztecs
with brains only one fourth the weight. An
inspection in these cases revealed the fact that
the cineritious portion was pale and that the
increased weight was due to the increase of the
white substance, and especially of its connec-
tive-tissue elements. Another deformation
met with in congenital feeble-mindedness is
a marked asymmetricality of the two sides
of the cranium. There is also in many an
increase of the facial development as com-
pared with the cranial. The ears are im-

CHILDHOOD AND YOUTH. 33

planted farther back relatively than in normal
heads. The eyes have their canthi too closely
approximated in the dolichocephahc cases and
too widely separated in the brachycephalic. The
palpebral fissures are often narrow and obliquely
placed, and the forehead is, not unfrequently,
corrugated in consequence of the employment
of the occipito-frontalis muscle to raise the lid.
At the inner canthi the integument often forms
semilunar folds as if the skin were too scanty,
which I have proposed to call epi-canthic
folds. These are met with in people who are
not feeble-minded, but they are more frequent
in the latter and are, I believe, signs of degene-
racy.

I have already referred to, and have else-
where described in detail, the deformations of
the mouth, which I regard as very important in
the diagnosis of congenital idiocy. These views
have been very generally adopted since I brought
them under the notice of the profession. They
have, however, been taken exception to in two
different quarters and for different reasons.
Dr. Kingsley, a distinguished dentist of New
York, did me the honour to say that he had
come to England mainly to discuss with me the

3

34 MENTAL AFFECTIONS OF

question and to see my cases. It was evident
to me that he had not had an opportunity of
studying the same kind of cases, and he stated
that he had met with the palates I have de-
scribed in people not feeble-minded. I am not
the less convinced that they are signs of degene-
racy which, sooner or later, culminate in feeble-
mindedness in the offspring, unless intermixed
with a stronger strain. This view was con-
firmed by many members of the Odontological
Society of London when I brought the subject
before them. Mr. Keeling said " he had been
induced to attend that meeting by the announce-
ment of the paper to be read by Dr. Langdon
Down. He had understood Dr. Down to ask for
information respecting the gradual degenera-
tion which might have taken place in the succes-
sive generations of the parents of imbecile chil-
dren. He was in a position to afford such infor-
mation. He knew the grandfather and mother
of an imbecile child (the latter, he had reason to
know, had been under the care of Dr. Down), and
if the discussion were postponed he should be
happy to produce the models of the mouths of
the grandfather and the mother, and, perhaps,
of the imbecile child's mouth also ; and the

CHILDHOOD AND YOUTH. 35

models would sliow that a very marked and
gradual deterioration of the palates and teeth
had taken place in the mouths of the individuals
referred to, from the grandfather to the imbecile
child." Mr. Oakley Coles said that he "for
some two years past had experimented upon
the anatomy and physiology of the palate, and
seemed to have been working side by side with
Dr. Down. His results to a great extent con-
firmed those of that gentleman." The late Mr»
Sercombe said, " Dr. Down's remarks about the
high vaulted palate and lunacy being commonly
associated had much struck him, and brought
to his mind the conditions of one of the oldest
families in the realm, who were patients of his,
in whom every branch of the family had re-
markably high V-shaped palates, and at least
two members of the family had been in con-
finement." The President of the Odontological
Society, the late Mr. Mummery, said " that he
had occasionally noticed, in cases where the
mental power was deficient, the front teeth
were not on the same plane as the molars," an
observation I am able to confirm. I am the
more desirous of placing these opinions of
members of the dental profession on record

36 MENTAL AFFECTIONS OF

here because Dr. Kingsley, since his return to
America, has read a paper " On the Develop-
ment of the Teeth " before the Odontological
Society of New York in which he reopens the
question and makes statements which are not
in harmony with my own experience. He says,
" In meditating some time since upon the sub-
ject I came to the conclusion that, if my
deductions were correct, I should find proof of
it in an examination of sluggish or feeble
intellect, and at that time I wrote this sen-
tence : ' In an examination of idiots we shall
be likely to find capacious jaws and teeth not
crowded.' If a precocious or stimulated brain
in infancy urges on and crowds the dental
organs in advance of the growth of the jaws,
then a brain of low calibre or power will be
likely to have associated with it a retarded
dentition, but with abundance of room. After
this conclusion of my own," he says, " I came
across a paper by Dr. Langdon Down. Dr.
Down's statements, founded upon his observa-
tions of nearly a thousand feeble-minded
patients, were so astounding, and so at variance
with my theory, that the picture which I had
painted seemed to vanish like a vision." Dr.

CHILDHOOD AND YOUTH. 37

Kingsley, however, visited an asylum for idiots
upon Rundall's Island in America, numbering
about two hundred, and did not see a single
pronounced case of V-shaped dental arch.
On visiting my patients he says that " there
was no mistaking the fact that there was a
larger percentage of the kind of deformities
which Dr. Down had described than I had
found in any other collection of feeble-minded."
Dr. Kingsley attributes the exceptional condi-
tion of the patients to their being members of
the higher orders of society, but the fact is
that my first observations were made on poorer
children at Earlswood.

An able physician in England, Dr. T. Claye
Shaw, has tried to show that there are many
idiots with well-formed mouths and palates,
and with this I agree if he includes acci-
dental and developmental cases. My contest
is that they are typical of the congenital class,
and one value attaching to these observa-
tions is that they often afibrd a means of
differentiating the latter from the two former
classes. Dr. Bourneville, of Paris, has car-
ried on investigations on the same subject in
France, and in a memoir has generally con-

38 MENTAL A T'P MOTIONS OF

firmed my views. Dr. Ireland, in his treatise
of ' Idiocy and Imbecility,' says, " Dr. T. Claye
Shaw took the trouble to write a paper to
prove that a highly arched palate is not a sign
of the existence of idiocy and imbecility ; that a
palatal investigation cannot afford a clue to
the mental faculties. Dr. T. Claye Shaw's
paper illustrates the confusion of mind one
must fall into who studies the physical aspects
of idiocy, while he persists in regarding it as a
class incapable of further subdivision."

The feeble-minded have a tendency to become
stout, with great development of adipose tissue ;
an example of this I related in the ' London Hos-
pital Reports ' with the results of medication
and diet.

Common sensation is generally much less
acute than in ordinary persons. Pain is borne
with wonderful callousness. It is not uncom-
mon for children of this class to allow a thecal
abscess to be opened with a scalpel without
a grimace or without uttering a word. The
same thing also applies to the extraction of
teeth. This is quite in harmony with what
may be expected ; the hyper-sensitiveness of
the cultured gentleman, as compared with the

CHILDHOOD AND YODTH. 39

untutored ploughman, is matter of everj-day
observation, well illustrated in the case of the
great Sir Eobert Peel, whose sensitiveness cost
him his life. Special sensation is also obtuse.
Hearing is generally less acute, and this is often
an important element in cases of delayed speech.
We all know that absence of speech is often the
outcome of complete deafness, but it is not
sufficiently recognised that a very slight con-
genital defect of hearing, is sufficient to cause
deferred and defective speech.

Lesions of sight are very frequent. Conge-
nital cataract is very commonly associated with
congenital feeble-mindedness. Several cases
have also come under my notice of blindness
the result of arrested development of the globe.
Strabismus is very common, and nystagmus,
though less common, is not infrequent. Myopia,
but especially hypermetropia, is a frequent
accompaniment of congenital mental lesions.
Colour-blindness is occasionally met with, but
it is difficult to say in how many cases it is from
a want of mental power. The sense of smell is
ill-developed in a great many and that of taste
keeps company therewith. The most nauseous
medicines are taken without question, and in

40 MENTAL AFFECTIONS OP

fact with many its administration is regarded
as a mark of attention and appreciated accord-
ingly.

The muscular system is weak. N"ot only are
physical efforts feeble, there is no power of
sustained endurance. Co-ordination is defec-
tive and finely adjusted movements are excep-
tional. There is a great tendency to automa-
tism and rhythmical actions. Salaams, hori-
zontal swayings, and rotations of the head and
body are often met with. The lack of muscu-
lar power makes itself painfully manifest in a
number of instances by the postponement of
walking or even of standing. This is a symp-
tom which brings children of this class under
the notice of the physician or sm^geon. The
mother mag:nifies all the little manifestions of
intelhgence, but she cannot understand why the
child does not walk. There may be no spastic
rigidity, no contractures, and yet the little legs
are powerless ; they would seem to be unable to
obey the behests of the will even were there any
will exercising its proper domain. In the large
number of notes which I possess of congenital
feeble-minded children, walking delayed to the
third or fourth year is a very common occur-

CHILDHOOD AND YOUTH. 41

rence. Imperfect prehension with the upper
extremities is also a frequent characteristic, and
often the vertical position is rendered impos-
sible by virtue of muscular weakness long after
children of a similar age are running about.

There is still one important character with
children of this class, which is a great cause of
anxiety, viz. postponed or absent speech. I
have, in describing the accidental forms of
feeble-mindedness, referred to speech as a
faculty which is frequently absent, and in the
" developmental " class as a faculty which,
having been once possessed, sometimes vanishes
at special epochs.

In the class we are now considering delayed
speech is universal, permanent absence less
common. The lesion of speech in these cases
is the outcome of several factors. The form
of the mouth is, as I have shown, often
abnormal. The high, narrow-vaulted palate
presents a formidable difficulty ; this is apt to
be intensified by the ill-development of the
lower jaw, the horizontal ramus forming too
obtuse an angle with the ascending ramus, so
that labials are expressed with difficulty. In
addition to this the tongue is large, flabby, and

42 MENTAL AFFECTIONS JN

defective in its muscular movementSj and these
are ill-co-ordinated. Again, the congenital
defective hearing I have referred to is often
another factor. Still further, there is too fre-
quently the potent cause of having no power to
convert ideas into words, and, alas, the still
more potent one of having no ideas to com-
municate.

I have thus, in the limited time at my dis-
posal, endeavoured to bring before you the
prominent features of what I regard as the
three great natural divisions of the sufferers
from a grave calamity. Some of the causes
which have produced it will occupy our time
at our next meeting.

CHILDHOOD AND YOUTH. 43

LECTURE II.

Causes of Idiocy. — Accidental Origin. — Developmental Origin.
— Congenital Origin. — Influence of Maternal Health ; of
Alcoholism ; of Malignant Disease and Syphilis ; of Neu-
rotic or Phthisical Inheritance ; of Trades and Professions ;
of Marriages of Consanguinity ; of Illegitimacy ; Idiocy
from, Deprivation of Senses ; Cretinism ; Influence of " Over-
Education " of Women.

The causes of idiocy or feeble-mindedness
will always attract a good deal of attention,
and will doubtless, as heretofore, lead to mucli
speculative opinion. It will be obvious from
tbe classification on which I have insisted that
the causes vary in their nature and their
date, in the three great divisions to which I
have referred. In the " accidental " variety
there is usually not much diflBculty in arriving
at the cause. The history, as a rule, elucidates
the matter. Some are from injury received at
birth by necessary instrumental interference,
but it is very remarkable how few are sacrificed
from this cause. Many years ago, when I was

44 MENTAL AFFECTIONS IN

assistant to the late Dr. Ramsbotham, I remem-
ber bis telling me that tbe cases were very few
in wbicb be could trace any cerebral lesion as
resulting from tbe employment of tbe forceps,
and be must bave known many instances wbere
tbe forceps, and especially tbe long forceps, bad
been applied less dexterously tban tbey would
bave been by bis marvellously accomplisbed
bands. During tbe later years of Dr. Ramsbo-
tbam's life I took great pains to investigate tbe
subject, and my results were greatly in accord
witb bis assertion.

I found tbat among tbe great number of
feeble-minded cbildren about wbom I could get
tborougbly reliable accounts, in only 3 per cent.,
including members of tbe tbree great classes,
bad tbe forceps or any otber instrument been
employed. It is probable, tberefore, tbat in 9
per cent, of purely accidental cases instrumental
interference migbt bave been tbe principal
factor. Far more important, bowever, in tbe
production of accidental cases, is tbe prolonged
transmission of tbe cbild in tbe maternal pas-
sages. In tbe preparation of a paper for tbe
Obstetrical Society of London I called attention
to tbe fact tbat in so large a proportion as 20

CHILDHOOD AND YOUTH. 45

per cent, of all idiots whose history I had in-
vestigated, there was an undoubted account of
suspended animation at birth — a suspension
requiring active efforts to bring about resusci-
tation. I believe that the members of our pro-
fession who have given attention to deformities
among children could say how very frequently
suspended animation at birth is associated with
the contractures and other lesions which they
are called upon to treat.

This cause is more frequently met with in
first-born children, for the very obvious reason
that the transit of the child is more likely to be
delayed to a perilous extent by the smallness of
the internal passages and the rigidity of the
peringeum usually associated with a primiparous
birth. Ergot of rye, when administered to the
mother during the parturient hours, has been
thought to be a cause of accidental idiocy, but
the result of my inquiries has been to establish
in my mind a verdict of " not proven." In
many of the cases in which ergot has been
employed, the very condition for which it was
used, viz. delayed transit of the child, has been
the cause of the evil rather than the agent
which was intended to hasten the birth. More-

46 MENTAL AFi<'ECT[ONS IN

over, it is extremely difficult to obtain from the
mother any information of what was or what
was not administered during the period of her
peril. The outcome of these remarks is, I
think, to show that, independently of what
concerns the safety of the mother, mental and
physical evil to the child is more likely to be
induced by prolonged pressure and a delayed
use of instruments than by the early and
adroit employment of agents likely to hasten
the birth.

Insolation in infancy is certainly a cause of
accidental idiocy. It has fallen to my lot to
see a notable number of feeble-minded children
who owe their disaster to sunstroke while making
the passage of the Red Sea and Suez Canal en
route from India, or from exposure in that
country. I have at the present time under my
care a very good example. There is every
reason to regard the case as an accidental one,
having reference to the history and the physical
configuration of the child, while the mental
decadence dates without question from the
period when exposure was unavoidable.

The administration of opium by nurses to
keep their charges quiet is often regarded by

CHILDHOOD AND YOUTH. 47

parents as a possible cause of their little one's
defect. From the nature of the case it is very
difficult to prove the administration of the
drug, and even if that be proved, to associate it
with the lesion. I am led to regard this as a
very infrequent cause of accidental idiocy,
inasmuch as the majority of the cases, where
strong assertions have been made as to the
furtive administration of the medicament, have
in their persons indubitable evidence of the
congenital nature of the malady, and, moreover,
evidence usually that the cause must be traced
far back in intra-uterine life. Much more tan-
gible as a cause is morbid sexual erethism, too
often induced by nurses who procure the quiet-
ness of their charge by means which, even if
the mental health is not sacrificed, lead even-
tually to grave moral delinquencies. A not in-
significant portion, however, break down, and
mental hebetude becomes their lot. I would
impress on you strongly my conviction that
this evil has a very early significance, and the
probability of the occurrence must always be
kept in view.

Traumatic injury to the cranium from falls
may be, and doubtless is, a cause of accidental

48 MENTAL AFFECTIONS IN

idiocy. It is readily conceivable that injuries
of this kind may prove harmful immediately by
concussion or later on by secondary lesions of
the brain and its membranes. I am persuaded,
however, that it is not so common as a cursory
consideration might lead one to believe. A
large number of cases are referred by the
mothers to falls or suspected falls, the objective
evidence of which is entirely opposed to such a
theory, cases in which the congenital nature of
the affection is beyond dispute. Traumatic
causes like opium drugging are, I am con-
vinced, but rarely factors in the production of
feeblemindedness.

Meningitis, on the other hand, very fre-
quently leads to this variety of idiocy. A large
number of cases of accidental idiocy have
somewhat of this history. They have been
born with nndoubted intelligence ; they have
contracted scarlatina, measles, or smallpox ; this
has been followed by inflammation of the ear
with extension to the membranes of the brain,
or the otitis may be set up by catarrh, the
inflammatory action extending from the outer
to the middle ear or from the pharynx by means
of the Eustachian tube. Whatever the origin

CHILDHOOD AND YOUTH. 49

death does not always take place, tlie little
sufferer undergoes a perilous illness with violent
convulsions, and, escaping with life, is not unfre-
quently left in a condition of mental feebleness.
I have made many autopsies in which there was
evidence of a long past inflammatory process
and in which there was a probability that the
anaemic condition of the cerebral convolutions
had for a cause the constringing effect on the
vessels, of organised lymph at the base of the
brain.

Epileptiform convulsions, whether eclampsio
or not, frequently cause accidental idiocy.
These may be induced by peripheral irritation
of any kind, and, as Dr. West has pointed out
in his suggestive and elegant Lumleian lectures,
" be the cause what it may by which the fit is first
excited, a paroxysm of whooping-cough or the
irritation of thread-worms,^ — something which
would seem most temporary in its character
and furthest removed from any abiding influence
on the higher endowments of the nervous
system, it yet leaves behind a mark, a stamp, a
stain, not unlike what theologians tell us of the
flaw which our first parents' sin has left upon
our moral nature, — a predisposition in short to

4

50 MENTAL AFFECTIONS IN

a great evil." It is, however, in the kind of
idiocy which I have termed " developmental "
that the results of epileptiform convulsions are
the most manifest.

Hydrocephalus is also an occasional cause of
accidental idiocy, more frequently, however,
of the congenital variety. I have had under my
care a few cases where the hydrocephalus
became developed after birth and lessened or
destroyed the intellectual faculties of the child.

Paralysis arising from cerebral haemorrhage
occurs as a cause of accidental as well as con-
genital idiocy. The amount of intellectual
defect varies greatly, some cases are very
amenable to instruction while others fail to
respond to the efforts made for their benefit.
In one case under my care the patient has been
taught to play the violin fairly well, well enough
to give him great pleasure, using the right
hand instead of the left for fingering.

We now come to the causes of developmental
idiocy, and I would first mention the maternal
health during pregnancy, which is, I am con-
vinced, a very potent factor in the production
of that kind of idiocy which I have named
" developmental," especially is it so if the devia-

CHILDHOOD AND YOUTH. 51

tion takes place during the sixth or seventh
month.

The causes which, occurring early in the
embryonic life of the child produce congenital,
operating later produce developmental idiocy,
by which I mean, as I explained in my first
lecture, children born with intelligence but
whose nervous and intellectual system breaks
down at one or other of the developmental
epochs.

The health deviations which lead up to this
kind of idiocy are sickness, whether produced
by the sea or other causes, uterine haemorrhage,
great emotional disturbance or grave febrile
disease. The members of this class are very
prone to eclampsia at first dentition, to epilepsy
or chorea at second dentition, and to epilepsy
or chorea, and moral deviations at the period
of puberty. At any of these epochs there may
be intellectual lesion varying in gravity with
the nature of the malady. It is of the greatest
importance that cases of this nature should be
kept free from all exciting causes of nerve dis-
turbance at the epochs referred to, and that
intellectual pressure should be disallowed if we
wish to avoid a greater catastrophe. With

52 MENTAL AFFECTIONS IN

care in tlie directions referred to many of this
class may escape the perils which want of
caution will certainly induce. This is especially
the class which breaks down from disturbing
causes during the early period of puberty, and
whose safety is only secured by frank exposi-
tion of the danger which results from moral
delinquency.

The majority, however, of the children about
whom opinion is desired falls properly under
the head of the congenital class, and if it be
asked, What is the cause of congenital idiocy ?
my reply is, that in a large number of cases one
must seek for several factors. The more one
inquires into the history of these cases the more
one is convinced that the simple causation
which has been referred to by several writers
is fallacious, and that in one case to attribute
It to intemperance only, in others to marriage
of consanguinity, is to take a narrow view of the
cause of the condition. I cannot but feel that the
inquiry really becomes an inquiry into the pre-
efficients or all that has gone to the making of
idiocy. There can, I think, be no doubt that
one of the great causes is heredity. It is im-
possible to devote much time to the elucidation

CHILDHOOD AND YOUTH. 53

of this subject without obtaining overwhelming
proof of the transmissible nature of neurotic
disease. If there are, as I am convinced,
physical indications of the congenital trouble,
there are also to be found in many of the pro-
genitors indications of decadence. In the in-
vestigation into the antecedent history of 2000
cases, in 36 per cent, of the fathers I failed to
get any history which could throw light upon
the affliction, and the same failure occurred
in 38 per cent, of the mothers, but in only 16
per cent, did I fail in obtaining a grave history
of physical or psychical decadence from one or
other of the progenitors. But even where there
was no evidence of gross departure from a
normal standard, one could not fail to notice
frequently cranial and other signs of racial
degeneration, such as narrow palates, rabbit
mouths, bad foreheads and facial exaggerations.
The causes of idiocy are not always operative
in a single generation, and it is only by having
the opportunity of examining into the physical
conformation of parents and grandparents that
one can see that idiocy in many cases is the
culmination in the individual of a gradual
degenerative process. Even with all the care

64 MENTAL AJi^PECTIONS IN

I have taken in the investigation I can
only hope that my results are approximately
correct. There is much difficulty in getting
the information one needs on account of mis-
takes respecting the import of one's questions,
and there are still further difficulties among
those whose education would enable them to
appreciate the inquiries made, owing to a desire
on their part to keep in the background many
points which would have a very important
bearing on the problem. I have often found it
useful to interrogate the parents separately,
and have in this way obtained very useful data,
each one in turn being not unwilling to supply
all the facts which would appear to point to
something in the opposite family as the potential
cause of the affliction. I have endeavoured
in such investigations to keep myself free from
the bias of former statistics, especially those of
the late Dr. Howe, of Massachusetts.

It had been a matter of speculation with me
whether great disparity of age of the parents
was not likely to be a cause, and strength was
given to this supposition by a few remarkable
cases which came under my observation — cases
where the disparity was very great and where

CHILDHOOD AND YOUTH. 65

fhere was feeble-mindedness in tlie offspring.
On making inquiries, however, over a large
field, I was led to results whicli, though, in-
teresting, did not tend to confirm the specu-
lative opinions I at first entertained. I found
that the average age of the fathers of feeble-
minded children at their birth was 35i\, and
that of the mothers Sl-fi^- ; a disparity of only
4^2 years. On looking about for some standard
of comparison I met with Mr. Galton's statistics
on the ages of the parents of men of scientific
attainments at the period of their children's
birth. Mr. Oalton states that their father's
average 36, and their mothers 30 years. With
reference to the ages of the fathers in whose
case we should naturally look for the potential
cause there is a remarkable similarity, the
advantage being on the side of the procreator
of feeble-minded children to the extent of -5^2"
of a year, while there is less disparity of age
among the parents of the feeble-minded than
among the parents of men of prominent ability.
The difference being six years in the case of
Mr. Galton's selected men's parents as against
4y2 in the case of the parents of afilicted ones.
It is clear, therefore, that disparity of age of

56 MENTAL AFFECTIONS IN

the parents, although doubtless having an im-
portant influence on the wellbeing of the off-
spring, does not rank as an important factor in
the production of idiocy.

It is worthy of remark that only 20 per cent, of
the mothers gave birth to idiots at the age which
Aristotle regarded as the most suitable one
for a vigorous progeny, viz. between thirty and
thirty-four. "Whereas, according to Mr. Gralton,
no less than 34 per cent, of men of eminence
are given birth to by their mothers at that age.

In a paper contributed to the Obstetrical
Society of London I have indicated that there is
a greater liability to idiocy among primiparous
children; 24 per cent, of the 2000 idiots exa-
mined by me being first-born children. I found
that seven was the average number of living
children born to those parents who have had an
idiot child, prolific child-bearing rather than the
opposite appearing to be the characteristic of
people begetting feeble-minded children. I
ventured to suggest that the preponderance of
idiocy in first-born children might be due to
the exalted emotional life of the father and
mother as well as to the increased difficulties
of parturition, and to the attendant greater risk

CHILDHOOD AND YOUTH. 57

of suspended animation to wMcIl I have already
referred. Curiously enough, while 24 per cent,
of idiots generally are primiparae no less than
40 per cent, of resuscitated idiots come under
this category. I have long held and taught the
opinion that suspension of animation must be
regarded as one of the pre-efficients of idiocy.

I do not find that the production of twins is
a very appreciable cause of idiocy. 2 per cent,
only of my collection were twins, while, on the
other hand, in 2 per cent, of my cases the
mothers had given birth to twins who were not
afflicted in any way.

I am aware that this opinion is rather differ-
ent from that entertained by Dr. Arthur Mit-
chell, C.B. His statistics on the subject are
somewhat different from mine. His observa-
tions were made in Scotland, and while I find
that one in fifty idiots is one of twins, he found
one in forty to come under this category.
Having regard to the greater tendency to
abnormal presentations, to the increased neces-
sity for instrumental interference, and the
greater liability to premature birth, I was pre-
pared to expect a much larger number of idiots
to have been twin children.

68 MENTAL AFFECTIONS IN

From what I have previously said it will be
seen that I attach immense importance to the
emotional life of the mother during the period
of pregnancy, and I feel convinced it is one of
the most potent of all the pre-efl&cients of
idiocy. In 32 per cent, of my cases there was
a well-ascertained history of great mental dis-
turbance on the part of the mother at that
time. My ever- to-be-revered teacher, the late
Dr. W. B. Carpenter, relates how at the Siege
of Landau in the year 1793, in addition to a
violent cannonading, which kept the women in
a constant state of alarm, the arsenal blew up
with a terrific explosion, which few could bear
with unshaken nerves. Out of 92 children
born in that district within a few months after-
wards 16 died at the time of birth, 33 languished
from eight to ten months and then died, 8
became idiots and died before the age of five
years, and 2 came into the world with numerous
fractures of the bones of the limbs, probably
caused by irregular uterine contractions. I
can from my own experience refer to the
number of cases of feeble-mindedness which
were the outcome of the Siege of Lucknow,
and in many others the result of sudden shocks

CHILDHOOD AND YOUTH. 59

from the receipt of distressing tidings of death
or other calamities.

Another element in the etiology of idiocy is
the physical health of the mother duriug the
period of pregnancy. In 20 per cent, of my cases
there was marked physical disturbance. In 4 per
cent, of these there was a history of serious falls,
falls from which uterine haemorrhage followed ;
the other cases were those in which there was
prolonged ill-health and in which vomiting
was a prominent symptom. They were all
such events or ailments as would be likely to
interfere with the nutritive life of the embryo.

By far the most potent influence in the pro-
duction of idiocy is the general physical and
mental health of the progenitors. This I have
already touched upon in speaking of heredity.
One cannot fail to be struck by the nature of
the stock from which such patients have sprung,
and one has not far to seek for most potent
causes. If, after a perusal of Mr. Glalton's
statistics of the antecedents of men of science,
we compare the antecedents of my 2000 cases,
the contrast is so great that all wonder at the
production of mental feebleness vanishes. With
fathers phthisical and irascible, with mothers

60 MENTAL AFFECTIONS IN

feeble in judgment and so emotional that every-
tliing is a cause of fright, one is astonished
that they should have procreated any sane
child at all, and, indeed, in some cases the
whole progeny of these parents is puny and
feeble, failing to perform social duties. I find
that in 16 per cent, of the cases there was
insanity or marked feeble-mindedness on the
father's side of the family, and in 15 per cent,
there was the same condition on the mother's
side. Severe emotional disturbance, bordering
on insanity, occurred in 4 per cent, of the
fathers, while a like affection in the mothers
occurred in 13 per cent. These cases of emo-
tional disturbance were very marked. Some of
uncontrollable passion, ill-regulated grief, or
morbid sentiment ; others where clergymen
had given up their cures through needless fear
of stopping in the middle of their sermons ;
others, again, where ruin had been brought
about by alienation of friends or ill-regulated
lives.

I have found it very difficult to get at reliable
statements with regard to the influence of alco-
holic intemperance. There is not only a desire
to conceal the fact, but there is evidently such an

CHILDHOOD AND YOUTH. CI

elastic gauge as to what constitutes intemper-
ance that my numbers must be regarded as
much within the truth. There was, however,
avowed and notorious intemperance in 12 per
cent, of the fathers and 2 per cent, of the
mothers. I found, however, that the propor-
tion varied extremely with the stratum of
society from which my records were taken. In
the members of the upper ranks in the social
scale it was an insignificant factor, while when
the inquiries related to the lower social class it
became a factor of great importance, and in
fact there appeared to be a gradually increasing
percentage as the lowest stratum was reached.

I feel quite sure that drunkenness must be
placed among the factors in the production of
idiocy. I have had under my observation several
families in which the majority of the children
were mentally feeble, and the whole more or
less fatuous, whose fathers were never very
drunk yet never perfectly sober, and in these
cases the chronic alcoholism had produced a
condition of mental hebetude from the slow
poisoning to which they were subjected.

Some of the cases are the result of slow
deterioration of the father's mental and physical

62 MENTAL AFFECTIONS IN

powers, others are the result of procreation
having taken place during a debauch. I have
elsewhere called attention to cases of idiocy
resulting from well-authenticated instances,
where procreation could only have occurred
under such a condition. Such cases have a
close family likeness to each other. Dr. Elam
states in ' A Physician's Problem,' that on
the removal of the spirit duty in Norway
insanity increased 50 per cent, and congenital
idiocy 150 per cent. Mr. Huth quotes from
Dr. Lannurien, of Morlaix in Bretagne, where
he says : "I do not hesitate to attribute the
greater number of cases of idiocy in this esta-
blishment to that cause," viz. alcoholism. I
certainly cannot bear that out by my experience
in England. Some years since, when I ex-
pressed my conviction that acute alcoholism
produced a distinct form of idiocy, it was
received with some questioning. I had, how-
ever, found, from conversation with M. Morel,
of Pouen, that he had noticed similar facts.
Dr. Puez has observed that idiocy was very
common among the miners of Westphalia, who,
living apart from their wives, only came home,
and generally got drunk, on their holidays.

CHILDHOOD AND YOUTH. 68

M. Demeaux lias also recorded parallel cases.
Dr. Delasiauve says that in the village of Careme,
whose riches were its vineyards, the inhabitants
were forced to be a little more sober in conse-
quence of ten years' vine disease. This, he says,
had a sensible effect in diminishing the cases of
idiocy. Demeaux assured himself that of thirty-
six epileptic patients he bad under his observa-
tion for twelve years, and whose history he was
able to trace, five were conceived in drunkenness.
He observed two children of the same family
suffering from congenital paraplegia whose
conception also took place while the father
was drunk.

I am not aware that any observations have
been made with reference to the relation of
malignant disease to idiocy, nor do I wish to
attach more importance to it than it deserves.
Nevertheless it is interesting to notice that 3
per cent, of the fathers and 5 per cent, of the
mothers, in all 8 per cent, of the progenitors,
died from cancer. Goitre occurred in 2 per
cent, of the mothers, but not once in a father.

I have made a very careful examination as
to the relation of syphilis to idiocy, and my
later inquiries have confirmed the opinion 1

64 MENTAL AFFECTIONS IN

have long taught, that syphilis is not an impor-
tant factor in the production of idiocy. In not
more than 2 per cent, are there signs of in-
herited syphilis. In making my investigations
I have availed myself of the valuable observa-
tions made some years since by my friend and
colleague Mr. Hutchinson, to whom the profes-
sion of medicine owes so much for his original
researches. Dr. Shuttleworth confirms my
opinion from investigation in another field.

I met with a history of epilepsy in 3 per cent,
of the fathers and in 6 per cent, of the mothers.
Phthisis exercises a very important influence
among the progenitors. Several years ago I
called the attention of the profession to this
circumstance, and endeavoured to show that
the peculiar form of idiocy to which I referred
in my previous lecture as the Mongolian type
was the outcome of a predominance of phthisis,
and that it included about 10 per cent, of all
idiots. I find that there is a marked history of
this disease in 25 per cent, of the fathers or
their immediate relatives, and the same thing
occurs in 20 per cent, of the mothers.

In 23 per cent, of the cases there was a
history of idiocy, mental feebleness, insanity, or

CHILDHOOD AND YOUTH. 65

other grave neurosis in one or several of the
brothers and sisters.

I have already alluded to the influence of the
emotional life of the mother on the embryo, but
I have also a large mass of evidence tending to
show that just as intemperance at the time of
procreation may eventuate in degenerate off-
spring, so various kinds of mental perturbation
of the father at that time may so result. I have,
for example, several instances of the father be-
getting healthy children, except when he was
the subject of recurrent mania, when idiocy
resulted to the children conceived at that time.
In like manner I have examples of healthy chil-
dren being produced except when the mer-
chant's business speculations have been hazard-
ous, when the clergyman's parish has been
disturbed, or the dissenting minister's church
meetings have been stormy.

There are many facts which tend to indicate
that the mental condition of the embryo takes
its impression from the mental condition of the
father at conception, and that there is a
markedly varying potentiality in the sperm-
cell.

It would be a very interesting question to

66 MENTAL AFFECTIONS IN

determine how far various trades and profes-
sions were allied with idiot offspring. I have
carefully investigated the matter but have
arrived at the conviction that I could not, from
my cases, although very numerous, draw any
very safe deductions. My patients have come
from all parts of the British dominions, and
include every variety of social rank, but still
I am conscious that a very unfair proportion
must have been drawn from this great city, that
although I may have accumulated a fair number
of histories from agricultural, I am sure there
is a deficiency of a due proportion of cases
from manufacturing districts, the great bulk
having come from the southern counties of
England and only a small proportion having
come to me from the great manufacturing
centres. I therefore feel I am unable to draw
any very safe deductions with regard to the
influence of employments generally in the pro-
duction of, or alliance with, feeble-mindedness.
Still there is a possibility of comparing the
relative association of this affliction with the
different professional classes, and especially with
what are termed the three learned professions.
I have collected from my notes four hundred

CHILDHOOD AND YOUTH. 67

cases with fair social antecedents, and I find that
75 per cent, are the children of merchants, coun-
try gentlemen, officers in the army and navy,
gentlemen of independent means and liberal
education, and members of the titled aristocracy.
No less a proportion than 25 per cent, are the
children of members of one or other of the
three learned professions, a proportion which
I take to be extremely large. On analysing
still further the cases supplied by these three
professions, I find that 3 per cent, are the chil-
dren of lawyers while 4 per cent, are the chil-
dren of members of my own profession. The
remarkable circumstance, however, in the in-
vestigation is that no less than 18 per cent, are
the children of members of the clerical profes-
sion. Mr. Galton has made some interesting
investigations from an opposite standpoint.
He takes the members of the councils of some
of the prominent scientific societies of London,
such as the Royal, the Linnsean, the Greological,
&c, and makes the very fair inference that the
100 Members of the Councils of such Societies
may be taken to be men of marked scientific
attainments and of intellectual prowess. He
inquires into the various professions of the men

68 MENTAL AFFECTIONS IN

who have had such representative offshoots.
He finds that the legal profession, which, accord-
to my statistics, procreates fewest idiots, gives
birth to 11 per cent, of the foremost men of
eminence ; that the medical profession with its
4 per cent, of idiots, gives origin to only 9 per
cent, of scientific men, while the clergy, who
have the maximum amount of idiocy, give birth
to only 6 per cent, of men of science. In other
words, while lawyers give origin to nearly three
times as many scientific men as do the clergy,
the clergy, on the other hand, beget six times as
many feeble-minded children as do lawyers.
Now, I venture to suggest that there is more
than a mere accident in this. I bring it for-
ward because, interesting in itself, it is also
interesting in the support it gives to the theory
that a process of natural selection has been
taking place.

The life of the lawyer is such as to aggregate
to that profession men of strong resolve, of
mental and physical vigour, men who must be
conscious that it is an avocation in which they
must bring to their aid an imperturbable will
and a good digestion. In the medical profes-
sion there is a larger average of moderate

CHILDHOOD AND YOUTH. 69

success. The race is not so urgent and the
claims not so imperious; an aggregation of
feebler elements is likely to ensue. But in the
clerical profession a moderate success is still
more ensured, and there is less claim among
the rank and file for great mental and physical
exertion. It is a profession which draws to-
wards it many good men, but whose goodness
need not be the outcome of great mental or
physical power. Moreover, when once within
the boundary of the Church, their usefulness
and success may be in direct proportion to their
retirement from intellectual turmoil, and to
their assiduous cultivation of the amenities of
life. It is a profession which, by its very gentle-
ness, is likely to draw to its enclosure less the
powerful will, the vigorous thought, and the
ratiocinative brain, than those with bodies weak
and emotions strong ; men who may be classed
as gently good rather than as grandly great.

The influence of marriage of consanguinity
on the production of idiocy has engaged much
consideration. There is a strong popular bias
in favour of the theory that marriages of consan-
guinity are an unmixed evil, and that they are
always subversive of physical and mental per-

70 MENTAL AFFECTIONS IN

fection. Mr. Huth has, however, in his classical
work on the marriages of near kin, brought an
amount of evidence on the other side of the
question which should make us hesitate before
we dogmatise on the subject.

About twenty years since I investigated the
matter, and have ever since kept it prominently
before me. I must confess that I approached
the question with a strong bias in favour of the
popular opinion. My inquiries, however, led
me to see that the whole subject was worthy of
reconsideration. The data on which accurate
calculations can be made are unfortunately
wanting, inasmuch as there is great uncertainty
as to the number of people born who are the
children of first cousins. I hope that at the
next census this may be remedied, and that we
may have reliable information on which to
build more conclusive arguments. We want
to know how many healthy and capable people,
men and women who are doing the world's
work, are the children of cousins, before we
can determine what, if any, influence the mar-
riage of cousins has in producing mental
feebleness. In the absence of such data I made
inquiries among the out-patients at the London

CHILDHOOD AND YOUTH. 71

Hospital, and found "5 per cent only were the
children of cousins. It is true that my area
was a limited one, and it is possible that the
percentage is a low one. However, the people
I did meet with who claimed to be the product
of consanguineous marriages were wonderfully
fine specimens of humanity. They were, as a
whole, really above the average in physique and
vigour. I made similar investigations among
the employes in an institution, and found ap-
proximately the same result. Other inquirers,
however, have made their results rather higher,
and have, therefore, in like proportion weakened
the argument against consanguineous unions.
Thus, M. Boudin, using the French of&cial re-
turns from 1853 to 1859 inclusive, says that of
every 100 mixed marriages, there were 9 con-
sanguineous, while from another official return
of marriages in France in the years 1863 to
1865, of every 100 mixed marriages 1'28 were
consanguineous. M. Dalby has shown that
having regard to the records obtained in the
offices of the Mairie at Paris, that the results
obtained both by M. Boudin and myself are
probably too low, and that 1*4 per cent, is the
proportion of consanguineous marriages in

72 MENTAL AFFECTIONS IN

Paris, a larger percentage than that derived
from the official returns of France generally.
Mr. George Darwin, in a paper read before
the Statistical Society, endeavours to arrive at
approximate results by a calculation based on
the number of same name marriages, and comes
to the conclusion that the ratio of consan-
guineous marriages in London is 1"5 per cent,
and in country districts 2*75 per cent. Having
regard, therefore, to results arrived at by dif-
ferent observers, I think that until we have
more authoritative data, 1 per cent, may be
taken as the percentage of marriage of first
cousins. Dr. Arthur Mitchell, C.B., estimates
them, at a rough guess, on the basis of his
inquiries in Scotland at 1'5 per cent.

Mr. Huth marshals a great many facts to
prove the position which he takes. He has no
difficulty in appealing to the early history of
the world to show that consanguineous mar-
riages were the rule. Close intermarriage was
practised by the great founders of the Hebrew
race. Among the Ancient Egyptians and
Persians he indicates that incestuous marriages
were common in the kings and people of high
rank without apparently any evil result, and he

CHILDHOOD AND YOUTH. 73

shows bj numberless appeals to Athenian and
Spartan history how frequent, and yet how
harmless, was marriage of near-of-kin. The
whole question has been discussed with an
amount of partisanship, which is very remark-
able. One disputant goes so far as to attribute
hydatids in the liver to consanguineous unions,
others again charge to marriages of near kin
'' organic degeneration fatal to the propagation
of the species."

Dr. Shuttleworth has recently published a
paper on the subject, in which he discusses the
question with marked moderation. His statis-
tics, gathered in the North of England, are
slightly different frora mine, gathered in the
South, and are on the surface less significant of
the danger of the unions we are discussing
than were mine. Although I have no doubt of
the care with which Dr. Shuttleworth's cases
were taken, there is always a danger of the
friends not appreciating the question, or of
desiring to conceal the relationship, and so
making the percentage of births from the union
of cousins too low. They are not so likely to
exaggerate the percentage by the assertion of
a relationship which does not exist. In a

74 MENTAL AFFECTIONS IN

careful examination of 852 cases of known
parentage I found tliat 60 were cliildren of
consanguineous marriages, or at tlie rate of 7
per cent., wliile among these 46 or 5 '4, per cent.,
were first cousins. Dr. Shuttleworth, in ana-
lysing 900 cases, found tliat 5*1 per cent, were
consanguineous marriages, and of these 2*9 per
cent, first cousin marriages. While Dr. Shuttle-
worth finds that 5 is the average number of chil-
dren born to relatives who have intermarried, I
find that the average number of children born
under like circumstances is 6*9. It will be
observed that the latter figures are not far
removed from the average of my 2000 cases,
which is 7, so that there is not much to be said
as to consanguineous marriages being less pro-
lific than others. I am conscious, moreover,
in considering my statistics and those of Dr.
Shuttleworth, that I am comparing things
which are not the same ; his cases do not include
epileptic children, whereas mine do. This
may account in some measure for the disparity.
Since I wrote on the subject twenty years ago
I have continued making observations, and have
no reason to materially alter the percentages at
which I then arrived. I have recently gone

CHILDHOOD AND YOUTH. 75

over tlie notes of 400 fresh cases ; tliey have
been taken v^ith great care, and I am certain
that no error has crept in. Of the 400, 26
were children of consanguineous unions, or 6^
per cent., a difference so small as rather to con-
firm the value of my statistics on the larger
number. Nineteen of these were the children
of j&rst cousins, or 4*75 per cent. ; 6 were chil-
dren of second cousins, and 1 of third. When
1 came to analyse my cases further I was
struck with the obvious causes of their feeble-
mindedness, other than the marriage of near
kin, which the notes of my cases brought to
light. I took out of my portfolio 20 unselected
cases, and on examining the Hfe-history of their
progenitors, I found that in 1 only was the
consanguinity of the parents the only discover-
able factor. I am convinced that frequently the
absence of investigation into the other possible
factors has led to such contradictory opinions
on this subject. Take an illustration from my
notes culled by chance from my portfolio.

J. T. W — , born in the parish of St. Luke's,
1866. His father is a lever escapement maker,
his mother worked as a tailoress before her
marriage. Father always subject to headache

*?Q MENTAL AFFECTIONS IN

and to dizziness, frequently to fainting. Mother
dreadfully nervous ; her uncle died insane ; had
a cousin imbecile; the grandmother also was
extremely nervous.

He is the first-born child and had five brothers;
two have died, one from a fit during whooping-
cough, and the other from bronchitis ; one of
those living is paralysed ; another, three years
and five months old, cannot talk. His father fell
down in a fainting fit (epilepsy ?) which fright-
ened his mother very much when five months
advanced in pregnancy and brought on uterine
haemorrhage. We read further that the father
and mother were first cousins, but it is absurd
to suppose that this was the most important
factor in the production of the child's idiocy.
No one could contemplate the union of two
such persons, whether related or not, without
predicting disastrous results to their progeny.
Although looked at superficially my statistics
are rather less favorable to the marriage of first
cousins than are those of many other observers,
I am strongly of opinion that, having regard to
the remarkable antecedent neurotic history of
the first cousins who have married and pro-
created feeble-minded children, the evil appa-

CPIILDHOOD AND YOUTH. 11

rently resulting is that where there is hereditary
predisposition the intermarriage of relations
determines the concurrence of two morbid
factors, and this may account for the undoubted
greater frequency of feeble-minded children
among the progeny of cousins than among those
of mixed marriages. My views are quite in
harmony with those of Dr. Charles Withington,
who regards morbid inheritance rather than
specific degenerative tendencies as accounting
for all infirmities met with in the offspring of
cousins.

It is interesting to note that Dr. Kerlin, of
Pennsylvania, a remarkably accurate observer,
arrives at precisely the same conclusion as I
have, that 7 per cent, of feeble-minded people
are the children of consanguineous marriages.

Dr. Voisin made a careful examination of
1077 of his patients at Bicetre and Salpetriere,
and in no instance could healthy consanguinity
be regarded as the cause of idiocy, epilepsy, or
insanity.

I have thus endeavoured to show that while
the marriage of cousins insures a degenerate
offspring where there is something morbid in
the family history — where phthisis, scrofula.

78 MENTAL AFFECTIONS IN

and especially the neuroses exist, I am by no
means sure tliat by a judicious selection of
cousins the race might not be improved. Dr.
Olouston thinks there seems to be a special
tendency for members of neurotic families to
intermarry, and that an afifective afi&nity
amongst such tends to love and marriage. I
must say that my experience, on the contrary,
would rather lead me to agree with Mr. Grant
Allen that "what we each fall in love with
individually, is our moral, mental, and physical
complement." The intermarriage of cousins
arises in all probability from their seeing and
knowing more of one another, without com-
mitting themselves to an engagement, than can
be possible in ordinary life. Other things
being equal, I cannot but believe that the
physiological law is more usually followed,
seeking our unlike and our opposite. However
that may be, there is no strong argument, in
my opinion, to be based on an inquiry into the
etiology of idiocy in favour of the doctrine that
consanguinity per se is an important factor in
the production of the evil, and that this doctrine
is held is shown by the writings of Devay, of
Lyons, who asserted '^that in pure consan-

CHILDHOOD AND YOUTH. 79

guinity, isolated from all circumstances of
hereditary disease, resides, i]}so facto, a principle
of organic vitiation." Commencing the inves-
tigation twenty years ago, and continuing it
up to the present time, I am able to agree with
Dr. Shuttleworth, that if a close scrutiny does
not reveal any hereditary weakness, neurotic or
otherwise, that the facts and figures alone will
not in all instances justify us in " forbidding
the banns."

Illegitimacy has been regarded as a cause of
idiocy. Dr. Arthur Mitchell, from statistics
taken in Scotland, where illegitimacy appears to
be frequent, came to the conclusion that it is a
very common cause. He supports the proba-
bility of this by reference to the superior viability
of legitimate as compared with illegitimate
children. Thus at Berlin every twenty-fifth
child of the legitimate and every twelfth child
of the illegitimate were stillborn, and after
birth the mortality of the legitimate before the
age of five years is to that of the illegitimate as
6 to 3.

I cannot but think that these statistics are
open to another explanation. My own inves-
tigations do not throw much light on the sub-

80 MENTAL AFFIiCTIONS IN

ject, because my 2000 cases are mainly from
children born in wedlock, the illegitimate cases
finding their way into the workhouses. Among
the few that have come under my notice where
there was reason to suspect their legitimacy,
there has been enough in the anxieties of the
mother's position to account for the disaster.
With the prospect of giving birth to a child
with a compromised position one cannot wonder
that the agony of mind incident to it, should
arrest the development of the embryo and give
rise either to congenital or developmental idiocy.
I am quite prepared, therefore, to expect that in
a different class than that from which my sta-
tistics are drawn illegitimacy may be a potent
emotional factor.

Attempts to produce abortion have been
also regarded as a cause, and it is possible that
this may be one among others to add to the
numbers of feeble-minded children the outcome
of illegitimacy. I am, however, not able from
my personal experience to confirm or negative
the statement.

Idiocy is occasionally induced by deprivation
of the senses. The case of Laura Bridgman
(although not an idiot) has become known

CHILDHOOD AND YOUTH. 81

wherever the English language is spoken, as a
triumph of the perseverance of the late Dr. Howe
over difficulties which seemed insurmountable.
I have had one such example under my care.
The subject of the deprivation was a boy who
could neither see, hear, nor speak, and this de-
privation was from birth. He had a very acute
sense of touch and that of smell was equally
good. He knew by their odour all those who
were brought into daily relation with him, and
caressed lovingly those who ministered to his
wants in the way of food and warmth. Attempts
were made to teach him to associate actions with
things, especially articles of food. I tried to
teach him a sign for sugar (of which he was
very fond) by the movement of the hand in a
vertical direction, but without success, although
it was repeated again and again with most
persevering efforts. It was, unfortunately, a
case in which there was a damaged cerebrum,
and he became epileptic. It was most remark-
able, however, how at once he smelled out his
friends and manifested by a smile his conscious-
ness of their proximity. That smile was always
a reproof to us, who had full possession of our
senses, for our occasional petulence at things of

6

82 MENTAL AFFECTIONS IN

minor import, wliile this deprived boy never
whined but appeared delighted at the most
insignificant creature comforts.

There is a very important class of cases which
owes its origin to malaria or other endemic
causes, and which is called Cretinism. A great
deal of attention has been given to this disease,
and I have had the opportunity of studying it
myself in the Italian Valley of Aosta. Here I
found it in greater profusion than in any of the
valleys of the Bavarian or Swiss Alps. The
fact that cretinism is not confined to the valleys
of mountainous regions but is found also along
the course of the great rivers, suggests the pro-
bability of its having a malarial origin. Every
variety of theory has been resorted to^ from the
presence of iron in the water to the presence of
magnesia. Cretinism is not unknown in Eng-
land, and has been found in Derbyshire and
some parts of Yorkshire, I have seen several
cases coming from one part of Somersetshire,
not to be distinguished in their general features
from those met with in the Swiss and Italian
valleys. Virchow and Zillner both trace a con-
nexion between marsh fever and acute affections
of the thyroid gland. Certain it is that, while

CHILDHOOD AND YOUTH. 83

the goitrous people are not necessarily cretins,
the race tends by a process of gradual deterior-
ation to cretinism. A large number of cretins
met with in the Yalley of Aosta were not goitrous
in the least degree, but their grandparents, who
were not cretins, had enormous thyroid glands
and the peculiar tawny look which is charac-
teristic of cretinism as well as of palludal poison-
ing. Cretinism is, however, met with in Eng-
land sporadically. My colleague, Mr. T. B.
Curling, was the first to call the attention of
the profession to these cases, in the year 1850.
Without having been aware of his paper I
brought a case before the Pathological Society
in 1869, having had cases under my observation
from the year 1860. I have now had altogether
twelve sporadic cretins under my care, and in
the majority there was reason to believe that
they were procreated during the intemperance
of the father, some of the later ones could not
have been procreated under any other condition.
They all had a very great resemblance to each
other, most of them had their growth arrested
at the period of first dentition, in three of the
number, however, growth was not arrested
until the period of second dentition. They all

84 MENTAL AFFECTIONS IN

had two characteristics ; there was no evidence
of the presence of a thyroid gland, and they all
had puffy swellings, which Mr. Curling showed
to be fatty, in the supraclavicular spaces. In
a case I have recently had under my care, and
who died a few months since from tubercular
meningitis, the supraclavicular swellings en-
tirely disappeared before death. Apparently it
was a reserve stock of fatty material, which
vanished with the general emaciation. The cha-
racteristics of these children are their extreme
placidity, they are unruffled in temper, seldom
cry, never shed tears. They are imitative and
have a strong sense of humour. Their speech
is usually deferred, and when acquired is mono-
syllabic. They are orderly and precise, dis-
turbed by anything out of the usual routine.
Their skin has a wrinkled appearance, as if too
large for their diminutive bodies. Their faces
have an earthy colour. The hair is com-
monly sparse, and they suffer from pityriasis of
the scalp. They have usually a large develop-
ment of areolar tissue, and two of my cases
were characterised by polysarcia, one weighing
210 lbs.

Three of my twelve cases were males, nine

CHILDHOOD AND YOUTH. 85

were females. Tliey all had brachyceplialic
crania, flattened noses, and tlie distances of
the inner canthi exaggerated. Their tongues
were large for their mouths, and their lips were
thick. There was in the majority a tendency
to suck their tongues. In three only was there
much intellectual response to teaching. They
were all, however, with one exception, readily
taught to be clean in their habits, making signs
to indicate their natural wants. Menstruation
had not appeared even in those who had
reached the years of womanhood, and the
external organs of generation were infantile in
appearance, and apparently there was complete
absence of sexual instinct.

In the year 1857, M. Baillarger presented a
case of sporadic cretinism before the Societe
Medico-Psychologique of Paris, and described
it as a very remarkable one. It is a girl, he
said, born at Melun, of healthy and well-formed
parents. The first dentition was completed at
three years of age, and it was then that general
development was arrested. The girl is now
about twenty-seven, and she has the intelligence
and tastes of a child of four or five ; she plays
with a doll, and has no sentiments of modesty.

86 MENTAL AFFECTIONS IN

After describing the characteristics of the case,
which resemble very closely those which I have
detailed as being common to mine, he goes on
to say that the body is fat, the limbs thick and
short and sufficiently regular ; the second denti-
tion only commenced at eighteen, and has not
yet terminated. The pubis is smooth, the
mammary glands rudimentary ; menstruation
has not been established, and there has never
been any sexual sensation. M. Baillarger
throws out the suggestion that the condition of
this case, and of another that he had seen in
Paris with M. Rayer, arose from inactivity of
the generative organs.

The relation between goitre and cretinism is
of extreme interest. The late Dr. Hilton Fagge
in 1871 regarded goitre and cretinism to be
antagonistic effects of the same cause. He sug-
gested that when the cause acts with little inten-
sity the sole effect is goitre, but if it acts with
great intensity or upon successive generations
it at length produces cretinism as well as goitre.
The not infrequent absence of goitre in cretins,
when not dependent upon congenital deficiency
of the thyroid body, must, he thought, be attri-
butable to some local morbid change in it, by

CHILDHOOD AND YOUTH. 87

■wMcli it is prevented from undergoing enlarge-
ment under the operation of the morbific agent.
He suggested that when goitre has existed in a
family for two or three generations, the struc-
ture of the thyroid body may undergo deteriora-
tion in members of the succeeding generation.
When we have regard to the remarkable cases
of cretinoid changes in adult women described
so well by Sir William Grull, and the many
examples which have been since accumulated by
many observers, and especially by Dr. Ord and
Sir Dyce Duckworth, we cannot fail to see the
close relation between cretinism and degenera-
tive changes in the thyroid. This is further
strengthened by the fact made known to us by
Professor Kocher, of Berne, that after the
removal of the thyroid for goitre, a condition
gradually supervenes which much resembles
adult cretinism, while Professor Horsley, opera-
ting on monkeys by removal of their thyroids,
has produced symptoms resembhng myxoedema
which, by virtue of the increase of mucin in the
tissues, is the name which has been proposed to
be given to the cretinoid condition described by
Sir WilHam Gull. It is very noticeable that
many of the physical as well as mental and

88 MENTAL AFFECTIONS IN

moral cliaracteristics of myxoedema resemble
those of sporadic cretinism, and, like it, occur
mostly in women. The only exception I have
seen was a cabdriver brought by Dr. Fenn, of
Richmond, before a meeting of the Thames
Valley branch of the British Medical Associa-
tion. I cannot but feel that the inquiries
which are being made with regard to myxoedema
will eventually throw light on the etiology of
endemic and sporadic cretinism.

There is one subject of great interest at the
present time which is made the topic of
addresses from presidential chairs as well as
of numerous articles in periodical literature. I
mean the higher education of women. The
doctrine which has been promulgated of late is,
that the higher culture of the faculties of women
will make them less capable of becoming
"mothers of men." There has been hitherto
no objection to their being taught everything
relating to art, music, or their emotional life,
but directly there are attempts made to cultivate
their judgment, to teach them how to reason,
to inculcate habits of self-control, we are met
by clamours which, in my opinion, are not based
on experience, and, so far as the etiology of

CHILDHOOD AND YOUTH. 89

feeble-mindedness is concerned, are likely to be
prejudicial. If there is one thing more certain
than another about the production of idiocy it
is the danger which arises from the culture of
only one side of a woman's nature ; so long as
only the emotional side of their nature is culti-
vated and they are responsive to the least un-
expected sound, unreasoning as to the world of
nature about them, and thrown into emotional
paroxysms by the sights and trials which will
be sure to cross their path, they will, from my
point of view, be liable to become the mothers
of idiots. Without advocating over-pressure,
which is as bad for the neurotic boy as for the
neurotic girl, and which is to be avoided during
the developmental life of the one as well as
during the developmental life of the other, there
can be no reason why the faculties which they
possess should not be cultivated so as to make
them not only fit to be " mothers of men " but
also companions and helpers of men. At all
events, let the trial be made without prejudice,
and let us welcome the advent of a time when
women shall not be the mere frivolous toys of
the hour but have and enjoy the privileges and
rights of which it is absurd to deprive them.

90 MENTAL AFFECTIONS IN

My statistics show that we must look mainly
to the health and mental life of the parents.
They point to the importance of training our
sons to be temperate and our daughters to be
self-possessed. They indicate that we should
seek alliances for our daughters with men from
a healthy stock, that our sons should avoid
women whose emotions are developed at the
sacrifice of their judgment and self-control.
They show that idiocy is often the natural out-
come of a gradual process in which the strain
becomes more and more degenerate, requiring
only an insignificant factor to produce the direst
results.

CHILDHOOD AND YOUTH. 91

LECTURE III.

Infantile Mania. — Melancholia and Delusions. — Moral Insanity.
— " Idiots Savants." — Variations in the Mental Condition.
— Epilepsy and Catalepsy. — Physical Deformities. — Asso-
ciated Diseases. — Bate of Growth. — Diagnosis of Idiocy. —
" BacJcward Children." — Deferred or Absent Speech. —
Morbid Anatomy. — Treatment of Feeble-mindedness.

Infantile mania is not of frequent occurrence
and has not been the subject of much comment,
Nevertheless very well-marked examples have
come under my notice in quite young children ;
cases where the various phases of insanity in the
adult have been well represented; acute maniacal
attacks, in which the patient tears and destroys
everything within reach, or creeps under tables
and sofas to hide, screaming with undisguised
rage and biting and scratching anyone who
approaches. This attack subsides and the
boy behaves as nicely and intelligently as pos-
sible, but in a few days has a recurrence with
as great violence as before. Some few years

92 MENTAL AFFECTIONS IN

since a little boy of this class was sent to me.
He was by no means deficient in mental acute-
ness, in many respects was precocious ; he was
an only child, and having lived a good deal with
adult people he talked rather sagely, but he
was liable to attacks of acute mania of a very
marked kind. There were no bounds to his
petulance and violence. He would attack his
father in the street and behave in all respects
in an insane manner, regardless of any injury
he might inflict, even on those for whom he
ordinarily entertained affection. In the inter-
vals of the paroxysms he manifested traits which
made him much liked by those about him.

Occasionally I have met with cases having
well-marked delusions of suspicion. The ordi-
nary trust and unsuspiciousness of childhood
has been replaced by painful mistrust. In one
case the child imagined that he was watched
and that someone was listening at the key-hole.
Another had delusions that things were mixed
with his food and had evident fear of being
poisoned. I have seen some cases of melan-
cholia associated with manifest delusions, one
boy believing that he resembled an animal and
frequently looking into the mirror to confirm

CHILDHOOD AND YOUTH. 93

or dissipate tlie conviction; another believed
that she would break if you touched her, and
the fear of falliug to pieces like a fragile piece
of glass was a real terror to her. I had some
years since under my observation a girl who,
when eight years of age, put her baby brother
on the fire so that he was dreadfully burnt.
The girl herself was ill-favoured in appearance
and she had been accustomed to hear the beauty
of her brother injudiciously praised. In a
maniacal attack she attempted to get rid of
the subject of so much laudation. About three
years subsequently she became epileptic and
again later on the subject of epileptic dementia.
It is highly probable that the maniacal paroxysm
which manifested itself in homicidal mania was
really masked epilepsy.

As puberty approaches attacks of mental
aberration assume a special character ; there is
frequently unnatural introspection and a critical
hyper-conscientiousness becomes prominent. I
have recently had five cases under my care
three boys and two girls. They have all had
characters much in common, they have all been
very good and studious children, but between
eleven and thirteen years of age have become

94 MENTAL AFFECTIONS IN

moody, have had conscientious scruples as to
their motives, have been anxious not only as to
whether they have told the truth, but whether
when having told it, they have done so in such
a way as to convey to others the precise idea
in their minds. They have had morbid views
as to the standard of right and wrong ; some-
times they have detailed things in a non-
sequential way. One boy was troubled when
he saw a dirty beggar-man or boy lest he should
contaminate his mother by thinking of her imme-
diately afterwards. I saw him greatly perturbed
one day from having seen an errand-boy come
to the school-house, and his thoughts flitting
to his mother he was rendered inexpressibly
miserable lest he had lowered, injured, and
contaminated her by unwittingly thinking at
the same time of her and the dirty boy. I have
sometimes known an avoidance of anything
positive in assertion lest the exact truth should
not be spoken, so that all the replies are, " Per-
haps it was," " It may have been," " I may
have done so and so," about things in which
no principle was involved, but from a morbid
fear of not saying what was true. These cases
cause great anxiety at the time and occasionally

CHILDHOOD AND YOUTH. 95

lead to a permanent breakdown. Many, how-
ever, by careful management may be tided over
the climacteric period of puberty and then all
may go well. It is important, however, to be on
guard against any concealed suicidal impulse,
and to note its slightest indication, as the ten-
dency in such cases is to melancholia and in some
instances temptation to self-inflicted injury.
Care should also be taken to be quite sure that
there is no sexual deviation, and if there be, to
treat it, not as moral wrong, which would
inevitably lead to further mental disquietude and
peril, but as a physical evil which, for the good
of the body, it is important should be corrected.
These deviations are readily recognised by the
aggregation of a group of symptoms which
rarely leads one astray. They are, supra-orbital
headache, dilated pupils, a brown-umber areola
surrounding the eyes, an averted look and a
statuesque bearing. This last symptom alone is
often very conclusive and may be regarded as
certain if associated with the preceding ; occa-
sionally the statuesqueness is so marked as to
resemble a minor cataleptic state.

Moral insanity is met with in childhood and
youth. It has fallen to my lot to have had a

96 MENTAL AFFECTIONS IN

great many illustrations brought under my
notice — cases of purposeless theft, purposeless
lying, and purposeless miscMef. They are
difficult cases to treat, and make great demands
on one's resources. The subjects of this condi-
tion are sometimes intellectually bright, and
have an amount of address which makes them
extremely troublesome to their friends and
those who have to guide them. I was consulted
some years since about a boy who displayed
such destructive energies on toys and every
household appliance that he could get into his
possession, that his friends thought it indicated
a latent mechanical talent, and as he had also
manifested mathematical ability he was appren-
ticed to a firm of engineers. Here his pleasure
in creating astonishment led him to introduce
sand into the mechanism of the machinery he
had to overlook, apparently getting amusement
out of the consternation and inquiry which his
evil deeds induced. He managed for some time
to conceal his delinquency by clever lies ; but at
length the mischief was fastened on him from
his having allowed a traversing machine to go
beyond its support in order that he might see
the mischief that would ensue. He had good

CHILDHOOD AND YOUTH. 97

musical talent, and acquiring some skill as an
organ player, he would play occasionally in
cliurcli, and suddenly stop to enjoy the discom-
fiture his irregularity produced. Eventually
he became a thief and was several times in
danger of being brought under the criminal law.
All his delinquencies were conceived and carried
out with great skill ; there was no intellectual
lesion, but his moral and affective faculties were
thoroughly dormant. He saw no wrong in what
he did and he entertained no affection for his
parents, who were in a state of perpetual agony.
Had he been a member of a lower stratum of
society he would have become a jail-bird.
Great pains were taken to prevent his getting
into the hands of the police, and, the period
of puberty passed, he has reached manhood
with improved moral sense, and is now getting
his living by his musical talent in a respectable
and honorable way.

More frequently moral insanity is associated
in children and youths with some amount of
mental backwardness. The backwardness may
be very slight, but yet sufficient to prevent
their taking appropriate place in form or in the
playground. The manifestations of moral

7

98 MENTAL AFFECTIONS IN

insanity in sucli cases are multiform. I have
seen a boy who had brought from school
sixteen watches without being discovered by
the sufferers or the principal of the school, and
this so cleverly done as for a long time to
elude detection. Another was dismissed from
school because he persisted in getting on the
roof and putting pillows and other articles
of bedding down the chimneys of neighbouring
houses in the terrace, or in filling the pillar
boxes with stones. Another would beg suffi-
cient money during the morning in the streets
to enable him to travel backward and forward
by the Underground Eailway the whole of
the remainder of the day. A still more
dangerous form is a tendency sometimes met
with of setting fire to articles of furniture,
often where it would be perilous to themselves
as well as others. Many forms of low cunning
are developed in backward boys by associating
them with others with more wit, who are also
bullies, the feebler one calling to his aid lying,
theft, and deceit, to compensate for his lessened
intellectual vigour. Again and again I have
seen the moral sense developed in boys of this
class when they have been removed from the

CHILDHOOD AND YOUTH. 99

bullying to which they had been subjected and
submitted to appropriate training. In all the
cases I have met with of moral insanity there
has been marked antecedent neurotic history.

This is a convenient place to treat of an in-
teresting class of cases for which the term
"idiots savants" has been given, and of which
a considerable number have come under my
observation. This name has been applied to
children who, while feeble-minded, exhibit special
faculties which are capable of being cultivated
to a very great extent. One youth was under
my care who could build exquisite model ships
from drawings, and carve with a great deal of
skill, who yet could not understand a sentence
— who had to have it dissected for him, and who,
when writing to his mother copied verbatim a
letter from ' The Life of Captain Hedley Yicars,'
by Miss Marsh, although it had not the slightest
appropriateness in word or sentiment. Another
has been under my care who can draw in crayons
with marvellous skill and feeling, in whom
nevertheless there was a comparative blank in
all the higher faculties of mind.

Extraordinary memory is often met with
associated with very great defect of reasoning

100 MENTAL AFFECTIONS IN

power. A boy came under my observation who,
having once read a book, could ever more
remember it. He would recite all the answers
in ' Magnall's Questions ' without an error,
giving in detail the numbers in the astronomical
division with the greatest accuracy. I dis-
covered, however, that it was simply a process
of verbal adhesion. I once gave him Gibbon's
' Rise and Fall of the Eoman Empire ' to read.
This he did, and on reading the third page he
skipped a line, found out his mistake and
retraced his steps ; ever after, when reciting
from memory the stately periods of Gribbon, he
would, on coming to the third page, skip the line
and go back and correct the error with as much
regularity as if it had been part of the regular
text. Later on his memory for recent reading
became less tenacious, but his recollection of
his earlier readings never failed him. Another
boy can tell the tune, words, and number
of nearly every hymn in * Hymns Ancient and
Modern.' Often the memory takes the form of
remembering dates and past events. Several
children under my observation have had this
faculty in an extraordinary degree. One boy
never fails to be able to tell the name and

CHILDHOOD AND YOUTH. 101

address of every confectioner's shop that he
has visited in London — and they have been
numerous — and can as readily tell the date of
every visit. Another can tell the time of arrival
of all the children at an institution, and could
supply accurate records in relation to it if
needed. Another knows the home address of
every resident who comes under his observation,
and they are by no means few. The faculty
of number is usually slightly developed with
feeble-minded children while memory is fairly
well developed, and yet I have had under my
observation cases where the power of mental
arithmetic existed to an astonishing extent.
One boy, about twelve years of age, could
multiply any three figures by three figures
with perfect accuracy, and as quickly as I could
write the six figures on paper, and yet, so low
mentally was he, that although having been for
two and a half years in almost the daily habit
of seeing me and talking to me, could not tell
my name. Another boy who has recently been
under my observation can multiply two figures
by two figures, while another can multiply
rapidly two figures by two, and a short time
since could multiply three figures by three

102 MENTAL AFFECTIONS IN

figures, but since an epileptiform attack has
lost this faculty to some extent. None of them
can explain how they do it, I mean, by what
mental process. When by rare chance they
have made a mistake, and some hesitation
has arisen, it has appeared to me, the plan
has been, to clear off the multiplication of
the higher figures first. Improvisation is an
occasional faculty. I had a boy under my care
who could take up a book, pretending to read,
an art he had not acquired, and improvise
stories of all kinds with a great deal of skill,
and in any variety, to suit the supposed tastes
of his auditors.

Memory of tune is a very common faculty
among the feeble-minded ; they readily acquire
simple airs, and rarely forget them. I have
had one boy under my observation who, if he
went to an opera, would carry away a recollec-
tion of all the airs, and would hum or sing
them correctly. In none of the cases of
"idiot savant" have I been able to trace any
history of a like faculty in the parents or in the
brothers and sisters, nor have I had any op-
portunity of making an autopsy, except in one
instance. This was in the case of a boy who

CHILDHOOD AND YOUTH. 103

had a very unusual faculty, of which I have
never since met another example, viz. the per-
fect appreciation of past or passing time. He
was seventeen years of age, and although not
understanding, so far as I could gather, the use
of a clock-face, could tell the time to a minute at
any part of the day, and in any situation. I
tried him on numberless occasions, and he always
answered with an amount of precision truly
remarkable. Grradually his response became less
ready, and he would not or could not reply unless
he was a little excited. He had to be shaken like
an old watch, and then the time would be truly
given. Gradually his health became enfeebled
and the faculty departed. At an autopsy I
found that there was no difference in his cere-
brum from an ordinary brain, except that he had
two well-marked and distinct soft commissures.
My explanation of the phenomenon was that
as every movement in the house was absolutely
punctual he had data from which he could esti-
mate the time by accurate appreciation of its
flux. All these cases of " idiots savants " were
males ; I have never met with a female.

It happens to the congenitally feeble-minded
as to the strong-minded to have deviations from

104 MENTAL AFFECTIONS IN

their normal standard. There is therefore
every form, of mental aberration to be met with
among them. They become the subjects of
acute and chronic mania, of acute and chronic
melancholia, and of dementia. It is curious to
witness the change which may take place in the
mental and moral condition of one deprived to
a great extent of intellectual power. Feeble-
minded children are not naturally suicidal ; they
are liable to meet with accidents from their not
having any sense of fear, or from not being able
to work out the logical sequence of any act,
but, under the influence of a melancholic state,
they do sometimes become suicidal. Occa-
sionally, under the influence of acute mania, the
feeble intellect of the youth becomes fanned
into a brighter flame, and he may say things
which are quite in advance of his ordinary
powers, becoming for the time quick in repartee
or pertly rude. The taciturn may become lo-
quacious, the timid and respectful proud and
defiant, and the amiable and tractable abusive
and destructive. Occasionally, too, a remark-
able change takes place in those who are tem-
porarily the subject of the delirium of fever.
Three remarkable instances have occurred to

CHILDHOOD AND YOUTH. 105

me of boys wlio had never been beard to speak,
making use of well-formed sentences during the
high febrile state of acute pneumonia in two
instances, and of scarlatina in another. In the
case of one, who was the subject of pneumonia,
the other boys who were in the Infirmary at
the time were frightened by the febrile ejacula-
tion of their usually speechless companion.

There are two ailments from which, according
to my experience, the congenitally feeble-minded
are remarkably free, viz. chorea and hysteria.
I cannot call to mind, among the large number
of cases that have come under my notice, a
single case of acute chorea. I have met with
cases of chronic and persistent inco-ordinated
movements, but not with the acute cases so
common in a general hospital or in a hospital
for children. I have assumed that it is partly
owing to the lessened emotional life of my
patients. The same reason may account for
the rare occurrence of hysteria. This defective
emotional element in the feeble-minded spares
them much grief. Although very afiectionate,
they will hear of the loss of beloved relations
or friends without emotional disturbance and
with a remarkable philosophy. They live very

106 MENTAL AFFECTIONS IN

mucli in tlie present, and are not perturbed by
the troubles of the past or the unexperienced
future.

Epilepsy is a very common complication of
feeble-mindedness. Of the whole number that
have come under my observation, 24 per cent,
have been at some period of their lives epileptic.
This appears to be a very large average and
indicates to what a great extent the treatment
of idiocy is the treatment of epilepsy. Dr.
Kerlin, of Pennsylvania, states that " from an
examination of the history of 300 imbecile
children between the ages of five and sixteen,
I find that 66, or 22 per cent., are now epilep-
tics." The percentage is so near my own as
to confirm very materially my observations.
My cases, however, are not within equally narrow
limits as to age, but range from two years to
forty. Dr. Kerlin further confirms my observa-
tions as to the important neurotic antecedents
of feeble-minded children, when he states that
62 per cent, have in their antecedents the
history of the epileptoid family of diseases. A
large number fall under the developmental
class and are often associated with a history of
eclampsia at first dentition. I have frequently

CHILDHOOD AND YOUTH. 107

observed attacks come on during second denti-
tion, followed by an interval of freedom until
tbe evolution of puberty. Epilepsy often
appears for tbe first time at puberty and subse-
quently ceases. Occasionally the status epi-
lepticus supervenes with the worst possible
results.

Catalepsy is met with among the feeble-
minded, but always in my experience asso-
ciated with impure habits.

The physical deviations of the feeble-minded
are very important. I have already referred to
the lessened common sensation and defective
co-ordination to which they are prone, to their
diminished sense of taste and smell, and to their
sight. Hearing is often obtuse, and is, as I have
said, frequently a cause of deferred speech.
They are very prone to eczematous eruptions
in the flexures of the joints and behind the ears.
The skin gives evidence of degeneration in its
tendency to unnatural unions ; just as the petals
of a corollifloral exogen indicate a lower grade
than the distinct petals of a thalamifloral so do
webbing of the fingers and toes and adhesions
of the lobules of the ear suggest marked in-
feriority. Dr. Laycock many years ago called

108 MENTAL AFFECTIONS IN

attention to the prevalence of ear abnormalities
in people of a degenerate type, and my own ob-
servations coincide with his. Lobules absent,
lobules adherent, helices defective, and the entire
pinnge misshapen or shrunken, are very common
among the congenital feeble-minded. The im-
plantation of the ear is often too far back,
giving an exaggerated facial development. I
have had under my observation very remark-
able examples of webbing, both of toes and
fingers, in all cases associated with adherent
lobules of the ears. The development of the hair
offers some anomalies ; some are hirsute over
their entire bodies, and 11 per cent, have the
eyebrows continuous over the nose. I have
before referred to the deformations of the mouth
and the importance I attach to these in dia-
gnosis. The tongue as a muscular organ is very
ill co-ordinated, and this is one factor in the
absence or defect of speech which is so charac-
teristic of the feeble-minded. In a number of
cases, taken without selection, of an age when
speech would be expected, 36 per cent, may be
regarded as being entirely dumb, and 30 per
cent, with speech indistinct, while not more
than 28 per cent, speak fluently ; the remaining

CHILDHOOD AND YOUTH. 109

6 per cent, speak a little and distinctly but
with a small vocabulary. Witli such retarded
development it is not astonishing to find
that puberty is postponed on an average two
years.

Mastication is often defective, partly from
carious teeth, and partly from a want of persis-
tent voluntary effort. Deglutition is often hur-
ried, and ill-masticated food is bolted. Rumina-
tion occasionally occurs. Three well-marked
examples have come under my notice ; in one of
the cases I found the oesophagus distinctly
pouched. They all eructated their food and
then placidly remasticated the mass. Excepting
when asleep, these were the quietest times of
their lives, being ordinarily restless and im-
patient. The whole process of feeding very
closely resembled that of the ruminants.

There is a great tendency to swallow unusual
things, such as pebbles and neckties, which gene-
rally prove quite inert. Occasionally, however,
the swallowed morsels are not so innocuous, and
there are now two or three deaths on record
from intestinal obstruction caused by the slow
accumulation of hair either bitten from their
own head or extracted from mattresses or from

110 MENTAL AFFECTIONS IN

swallowing a fibre at a time, picked out of cocoa-
nut matting. As might be supposed from tlie
defective innervation which characterises feeble-
minded children they are neither fleet nor per-
sistent in endurance. They are deficient in
muscular power as they are also deficient in
mental tension. The organs of reproduction
are ill developed ; among females I have found
a great prevalence of small ovaries, and in the
males 8 per cent, of those who have reached the
age of fourteen have either undeveloped or un-
descended testes. In recording this estimate
it is worthy of remark that both accidental,
developmental, and congenital feeble-minded
youths are included, and I have no doubt that
if the investigation had been confined to con-
genital cases the percentage of defective gene-
rative organs would have been much greater.

I have omitted to speak of one very marked
characteristic of the nervous system, viz. defec-
tive reflex functions. The feeble-minded are
very prone to constipation, and it is extremely
difiScult to produce emesis ; they resist any ordi-
nary dose of an emetic nature. On the occasion
of several children who had returned from a
day's holiday complaining of similar pains in

CHILDHOOD AND YOUTH. Ill

their stomachs, which gave rise to the suspicion
that some article of food had been unwholesome,
attempts were made to induce vomiting by the
administration of twenty grains of sulphate of
zinc to each, but in not a single case was it
successful, although the fauces were also irri-
tated by a feather. The same thing applies to
the absence of cough and expectoration when
they are the subjects of phthisis. It is not un-
common for a feeble-minded patient to pass
through all the stages of this disease without
the slightest cough. Their vaso-motor system,
on the other hand, is very sensitive ; they are
prone to gastric intestinal trouble from sudden
change of weather, from bolting their food, from
taking too much food at a meal, and from too
great predominance of meat as an article of diet,
or from the presence of electrical disturbance.
Occasionally, but not frequently, feeble-minded-
ness is associated with disseminated sclerosis,
with its characteristic gait and scanning speech ;
more frequently, however, with pseudo-hyper-
trophic paralysis, two well-marked cases of
which I have published in the 'Pathological
Transactions,' and several others have been
under my observation. In fact, I have seen but

112 MENTAL AFFECTIONS IN

few examples of that disease which have not
been also characterised by some amount of
intellectual lesion. Diseases of the kidneys
and liver are extremely rare, on account of
the discreet and temperate habits which such,
patients are accustomed to lead under medical
guidance. Rheumatism is very exceptional,
probably from the non-exposure to bad weather
which the nature of their lives induces. Put-
ting aside the diseases of childhood, diseases of
the brain and of the lungs are the chief causes
of death. Having regard to the frequency of
epilepsy as a complication, it is not surprising
that it should be a cause of considerable mor-
tality among the feeble-minded. I find, from
the returns of Dr. Fletcher Beach, that about
2^ per cent, of the average daily number of
inmates of the schools at Darenth. die from
epilepsy, or more than the mortality of London
from all causes whatever.

The prevalence of phthisis as a cause of death
among the feeble-minded varies very much with,
the nature of the soil on which they reside.
Through the admirable researches of Dr. G.
Buchanan we now know how much associated a
damp clay soil is with the existence of phthisis.

CHILDHOOD AND YOUTH. 113

He has taught us that measures which have been
taken in some towns and cities for their drainage
in consequence of the prevalence of zymotic dis-
ease, have resulted in diminishing the mortality
from pulmonary consumption in a remarkable
degree.

My own experience lends support, if support
were needed, to Dr. Buchanan's view. In the
year 1867 I wrote a paper in the * Lancet ' " On
the Relation of Idiocy to Tuberculosis," in
which I showed how prevalent phthisis was
among idiots, amounting to 39' 8 per cent, of
the general mortality. My experience since
that time has suo^ffested that I oua-ht rather to
have headed my paper, " On the Relation of
Tuberculosis to a Clay Soil." My observations
were made on 1000 feet of Wealden Clay, and I
did not know at that time what a relationship
existed between the two. My more recent ex-
perience on a gravel soil shows the deaths from
phthisis to be only 12 per cent, of the general
jnortahty. I concluded my paper with this
paragraph : " It is no less clear to me that
idiocy of a non-tubercular origin leads to tuber-
culosis. Whether this arises through the in-
fluence of the pneumogastric nerve, mal-assimi-

114 MENTAL AFFECTIONS IN

lation of food, or defective innervation, it cannot
but be regarded that the connection between
these maladies is by no means accidental, and
that a due appreciation of this relation is neces-
sary to those who would treat effectively con-
genital mental lesions." I feel it my duty to add
to this that the question of soil is an important
matter which I then overlooked. When we
have regard to the number of days in which
outdoor exercise is impossible on a clay soil in
a climate like that of England, the difficulty of
draining it effectively, and the damp exhalations
which the clay gives out in warm, and the mist
which is condensed in cold weather, we can
appreciate the effect it is likely to have on
children and youths whose ordinary mortality is
greater than that of those with normal nervous
power and nutritive energy.

Nothing is more remarkable than the readi-
ness with which feeble-minded children succumb
to acute disease of any form, or the way in which
they are injuriously affected by climatic changes.
The incidence of illness should be narrowly
looked for and promptly treated ; the thermo-
meter is of great value in indicating the need
of early precautionary measures. Before the

CHILDHOOD AND YOUTH. 115

introduction of the clinical thermometer the
principal indication of deviation from health
was loss of appetite. I have known a boy in
whose case the first suggestion of illness con-
sisted of a face sufiused with tears, because,
as he said, the boy who had sat next him at
tea had eaten three slices of bread and butter
and he could not eat any. This was the pre-
lude to one of the most serious ailments to
which the feeble-minded are subject, namely,
broncho-pneumonia.

My own observations as regards the height
and weight of idiots are very much in harmony
with those of Dr. Shuttle worth, and Dr. Tarbell
of America. I find that feeble-minded children
are shorter and lighter than the normal stan-
dard, and agree with Mr. Charles Roberts,
" that the relative rate of growth of the two
sexes of idiot children follows the same rule as
that of normal children, and is subject to the
same variations at the age of puberty." " It
was found by Dr. Bowditch," so writes Dr.
Tarbell, " in his investigation of normal chil-
dren, that until the age of eleven or twelve
years boys are both taller and heavier than girls
of the same age. At this period of life girls

116 MENTAL AFFECTIONS IN

begin to grow very rapidly, and for the next two
or three years surpass boys of the same age
both in height and weight. Boys then acquire
and retain a size superior to that of girls, who
have now nearly completed their full growth."
The diagnosis of idiocy is of importance, both
in order that the child may early be put under
proper training and for medico-legal purposes.
The profound cases are not difficult to diagnose,
especially if associated with microcephalism or
with marked asymmetry of cranium. The con-
genital class is that which has to be consid-
ered in early life. There is a marked want of
muscular power, as indicated by the inability to
support the head and to use the hands for pre-
hension. The eyes look out as if on an object-
less world, and the attention is not arrested by
the usual expedients to excite recognition in
infants. To the most loving endearments there
is no responsive smile, and the infantile cooing
is replaced by a wailing cry. The instinctive
process of feeding is often acquired with diffi-
culty and indicates, what I have long observed,
that there is no predominance of instinct in
idiocy. On the contrary, so far as instinct
itself is concerned, the young animal is on a

CHILDHOOD AND YOUTH. 117

higher platform than an idiot baby. Tho latter
would not search out the source of the maternal
supply nor make successful efforts to regain the
nipple if once out of the mouth. Later on there
is a marked indisposition to make muscular effort,
there is no responsive leap when the feet are
allowed to touch the ground, and when taken
in the hands the scapular muscles offer no resist-
ance, and the arms helplessly extend themselves
over the head. There is no disposition to
crawl but rather to lie on the back in an irreso-
lute way. Still later the power of standing is
deferred, and walking is an accomplishment
which may never be attained.

I have already referred to the physical devia-
tions in congenital idiots, such as the deformed
cranium, the vaulted palate, and ill-developed
ears, and these come to our aid in a remarkable
way in the question of diagnosis. The same
may be said of the ethnic characteristics, espe-
cially the Mongolian type, which is so signifi-
cant of congenital mental incapacity. In the
developmental class I have already referred to
the prow-shaped frontal bone as being highly
typical and an aid to diagnosis, certainly helping
us to assign a case to this division where there

118 MENTAL AFFECTIONS IN

are psycliological grounds for apprehending
mental dej&ciency. Witli regard to the acci-
dental class, physical deviations do not come to
our aid. They have usually none of the grave
deviations of conformation which we meet with
in the congenital class. They have, as I have
said, nothing in their look which would indicate
their mental decadence. On the contrary, they
in most cases during their childhood present
physical features but little indicative of the
terrible disaster which has bfefallen them;
except in the paralysed sub-class they are fleet
and mobile, and mischievous to a degree.
They are irritated by constraint, are intolerant
of having their heads examined, and try to
escape from one's ken, they pull open every
drawer that is unlocked, shake the handle of
the room door to procure its opening, and
sweep with their hand the ornaments off one's
table that they may enjoy the rattle. They
alternate their mischievous pranks with shrill
and unmeaning cries. They rarely speak, are
fond of feeling things with their tongues, and
run about to get some fresh object on which to
indulge this freak. They too frequently return
a preferred kiss by a bite, and fill up the

CHILDHOOD AND YOUTH. 119

intervals of their mobile mischievousness by
blowing bubbles with saliva on their lips.
They have this important diagnostic feature,
that they live entirely in a world of their own ;
they do not listen with a childlike curiosity to
the conversation which is going on in their
presence, — a conversation which is all-important
to them, and in the outcome of which they are
the most interested parties. They hear what
is said, but they do not attend, nor can their
attention be arrested, except by diverting them
into new channels by a more attractive trail.
They have usually great intensity of purpose,
and succeed in having their own way, the
mothers giving up the contest for the sake
of peace. Slavering is a very common sign
among the members of the three classes, arising
sometimes from inattention, or from hypersemic
condition of the salivary glands, from pro-
gnathous form of jaw and inadequate size, or
want of muscular power of lip, from inco-ordi-
nate movements of the tongue, and sometimes
from a combination of two or more of these
conditions. Automatic movements are also
very common ; these may consist of rotatory
movements of the head on its axis, of the body

120 MENTAL AFFECTIONS IN

from side to side, or from back to front, or rhytt-
mical movements of tlie fingers before the eyes.
There are a large number of boys and girls
wbo are dull and backward and who develop
tardily, but do arrive at last at a fair amount
of intellectual power. They are the enfants
arrieres of the French writers. It is very
important that their condition should be diffe-
rentiated from that of idiots. Their state
gives rise to much solicitude, and the pro-
gnosis depends very much on a right apprecia-
tion of their condition, as they respond very
much to proper training. The test which I
have found most useful is one suggested in the
first instance by Dr. Charles West. In any
given case we have to ask ourselves, — Can we in
imagination put back the age two or more years,
and arrive thus at a time perfectly consistent
with the mental condition of our patient ? If
he be a backward child we shall have no diffi-
culty in saying what period of life would be in
harmony with his state. If, however, he be an
idiot there is no amount of imaginary antedated
age to which the present condition of the child
corresponds.

I have already referred to the frequency with

CHILDHOOD AND YOUTH. 121

whicli lesions of speech occur among tlie feeble-
minded. They often constitute a basis of great
interest and importance for a diagnosis. The
absence of speech when a child arrives at five
or six years of age is in itself a matter for grave
anxiety. It will be usually possible to refer
the condition to one of three causes : (1) The
child is completely deaf or has some shght con-
genital defect of hearing ; or (2) there is some
defect of conformation in the tongue, palate, or
lips which prevents language being acquired;
or (3) the child is defective in mental power, and
either does not require speech from the absence
of ideas or has an inability to convert ideas into
words. Even when speech does exist it is often
echo-like. I have had several children under
my observation, in whom this kind of talking is
characteristic— To my question, " How are you
to-day ? " came the immediate reply, " To-day."
I ask another, " Are you a good girl ? " the re-
sponse is simply" Girl." Many such cases, how-
ever, maybe gradually led to intelligent response.
Sometimes the whole question is repeated, and
the echo is not simply that of the last word.
Often the absence of speech is associated with,
a perfect understanding of what is said, the

122 MENTAL AFFECTIONS IN

speecli faculty being a later development than
the capacity for understanding spoken words.
Gesture language frequently takes tlie place of
spoken language in the feeble-minded. The
want of speech is scarcely ever recognised by
friends or relations as the outcome of feeble-
mindededness. " My child," says almost invari-
ably the mother or father, " has no deficiency
except that he does not talk." When the child is
being trained the parents regard the acquisition
of, or improvement in, speech as the touchstone
of progress, disregarding a number of other
faculties which have been developed, or evil
propensities which have been effaced. In many
cases they are right, the absence of speech
without deafness or deformity being a very im-
portant indication of a grave mental lesion.

A fertile field for the investigation of the
morbid anatomy of idiocy is opened up by
the enquiries of Hitzig, Jackson, and Terrier
into the localisation of function, and by im-
proved microscopy aided by the use of staining
agents. A very prominent characteristic is the
diminished weight of the encephalon. Some-
times the diminution is very great, as in the

CHILDHOOD AND YOUTH. 123

microceptialic or Aztec variety. I have had the
opportunity of examining several, but the most
complete example was the brother of the boy
described by Professor Marshall in the ' Trans-
actions ' of the Royal Society. The brother in
question was for some years under my care, and
was an extremely good example of the suscepti-
bihty to education of even most unpromising
cases. He acquired language, read books with
simple words, amused himself with pictures,
and much enjoyed life. He was very agile,
but always rested himself by placing his hands
upon his knees, and when he ran he did so with
his head far in advance of his body in a simian-
like manner. He had a copious gesture lan-
guage, which he had adopted before he acquired
speech, and when he spoke he opened and shut
his eyes and shook his head in a manner very
suggestive of one of the quadrumana. He died
at the age of eighteen. His mother had only
given birth to two children, and they were both,
as I have said, microcephalic. There was a
history of extreme alcoholic intemperance on
the part of the father, who died prematurely
therefrom. The boy was 56 inches in height
and weighed only 89 lbs . He died from phthisis

124 MENTAL AFFECTIONS IN

with caseous deposit in his lungs and with more
recent disseminated tubercle.

His head measured 15 inches in circum-
ference. Its antero-posterior curve was 8 inches.
Its bilateral curve 8 inches. Its antero-pos-
terior diameter 5 inches, and its bilateral
diameter 3 "9 inches. The encephalon with its
membranes weighed 15 ounces. The cerebrum
was 4*2 inches long, 3"9 inches wide, and 1*8
inches high. It was attenuated in the occipital
region in length, width and depth.

The departure from the ordinary course
of development arose in all probability at an
early period in the history of the germ. The
convolutions which were best developed were
those of the frontal, parietal, and temporal
regions, while those less so were the orbital,
but especially the occipital region. The central
lobe, or Island of Reil, was represented only
by a slightly elevated prominence. Gratiolet
laid great stress on the supra-marginal lobule
as characteristic of man ; in this brain, how-
ever, the whole was reduced to the smallest
possible size, while the bent fold was dispro-
portionately large. Certainly the conformation
is not explicable by reference merely to re-

CHILDHOOD AND YODTH. 125

tarded growth, and lends, therefore, no coun-
tenance to the arguments of those who regard
microcephalic brains as due simply to syn-
ostosis. In this case the sutures of the cranium
remained with remarkable distinctness. The
defect was one of development, and not of
growth merely. The evidence of this is derived
from the modification of the cerebral convolu-
tions and the simplicity of their form. While
all the parts of the perfect human cerebrum
were represented, they, in a large number of
cases, rivalled in simplicity the quadrumauous
type. Like the brain described by Professor
Marshall, the simplicity of arrangement was not
equal throughout the whole of the convolutions,
and here again some additional proof was
oflPered of the arrest in development not having
taken place at a definite period of embryonic
existence.

On comparing this brain with that of his
brother, it was noticed that while the parietal
reo-ion remained the same, the frontal exceeded
it in size. How far this was the result of the
physical training to which he had been submitted
one can only surmise. Certain it is that it is
the only part of the brain which was proper-

126 MEi^TAL APFEOTIONS IN

tionately larger than that of his brother, while
the occipital lobe appeared to have undergone
but little developmental change. Comparing
his convolutions with those of the orang and
chimpanzee they appeared to be less complex,
the convolutions being smoother and less dis-
turbed by secondary sulci. The absence of a
well-defined supra-marginal lobule, the absence
of the second connecting convolution, the sim-
plicity of the bent convolution, the presence of
the calcarine lobule, the absence of the acces-
sory fold which unites the lobule of the second
ascending fold to the superior marginal lobule,
were all characters which approximated it to
the quadrumanous brain. On the other hand,
the want of symmetry, the presence of several
of the external connecting folds, the absence of
an operculum, the position from which the bent
fold took its rise in reference to the fissure of
Sylvius, the complete absence of the two inter-
nal connecting convolutions, and, lastly, the
complete junction between the calloso-marginal
and the middle temporal or uncinate convolu-
tions were characters essentially human.

Cases of extreme asymmetrically developed
brains are not infrequent ; a very characteristic

CHILDHOOD AND YOUTH.

127

example I published in vol. xx of the " Patho-
logical Transactions,' and many similar ones
have come under my observation. The most
frequent want of development is that of the
occipital lobe. Where there is any approach
to smallness of the brain this lobe is the
part which shows greatest want of develop-
ment. This condition has been noted in a case
reported by Dr. Shuttleworth, in which the
frontal and parietal lobes were fairly well deve-
loped but the occipital lobe was quite rudimen-
tary. Dr. Fletcher Beach has also pubhshed
some cases of microcephahsm where the defec-
tive development of the occipital lobe was very
marked.

Hypertrophy of the brain is not infre-
quently met with. In one very remarkable case
that came under my observation there was the
co-existence of a huge cranium with all the
sutures completely ossified. So thoroughly was
this the case that if it had occurred with a
microcephalic cranium it would have been a
strong argument in favour of the causal influ-
ence of premature synostosis in microcephahsm.
In another case the cranium was remarkably
and uniformly thickened, and the brain weighed

128 MENTAL AFFECTIONS IN

sixty-two ounces. On removing tlie dura mater
tlie entire surface of tlie encephalon presented
a blanc-mange appearance, in great measure
obscuring the outline of the convolutions, which
had great simplicity. The opacity appeared to
be due to the presence of lymph, in the sub-
arachnoid space, in the meshes of which lymph,
limpid serum was contained. The substance
of the brain was very tough and the cineritious
portion pale. The subject was only fifteen years
of age, and was remarkably stolid and irre-
sponsive to all external impressions. Dr.
Fletcher Beach has published a collection of
cases which well illustrate hypertrophic condi-
tions of the brain.

Absence, more or less complete, of the com-
missures is met with. In 2 per cent, of the
cases I have examined there has been almost
entire absence of the corpus callosum, and in 8
per cent, absence of the soft commissure.

Pallor of the grey portion of the encephalon
is very frequently met with in the brains of
feeble-minded children. Looking back over my
post-mortem notes, nothing is more striking
than the frequency with which extreme pallor is
mentioned. I cannot but think that this affords

CHILDHOOD AND YOUTH. 129

indications for treatment as well as a basis for
hopefulness in the possible functional improve-
ment of the cerebrum.

The treatment of the various phases of feeble-
mindedness resolves itself into medical and
physical; and training, both moral and intel-
lectual. The importance of commencing this
betimes cannot be too much insisted on. Early
training is of importance in preventing the
growth of bad habits which become engrafted
on the child. Constantly one meets with chil-
dren who grow up a trouble to themselves and
to those around them, from the injudicious
treatment of some ignorant nurse who tyrannises
over the family by her supposed essential rela-
tion to the child. Much time is often required
to undo the evil — even if it be capable of being
counteracted.

There are two great hindrances to the early
and successful training of feeble-minded chil-
dren arising from misconceptions on the part
of many members of the medical profession.
It is constantly said to the anxious parents of
these children, "Do not be troubled, the child
will grow out of it; wait till he reaches seven
years," or, if the child has reached that age,

9

130 MENTAL AFFECTIONS OF

then wait till he has reached fourteen. I know
nothing of cataclysmal improvements, such as
are here indicated. The opinion and advice
have no bases in experience. The septennial
periods referred to are periods of anxiety and
peril ; they are not periods of sudden leaps
from mental feebleness to mental vigour; they
are, on the contrary, developmental crises full
of danger, periods when wreck of what mental
power exists is liable to take place. How often
one has cause to lament the precious time lost
by the parents being thus lured into a fool's
paradise ! It should be remembered that the
increments of intelligence are slow ; that every
proper habit has to be implanted; that many
things which are thought instinctive and appear
to come naturally, have, with painstaking soli-
citude, to be taught. Bad habits of the most
serious kind spring up which militate against
the progress of the child while waiting for the
sudden change which never comes.

The other great mistake in the medical advice
which is often given is the insistance to the
mother that her child should not mix or be
trained with children like himself, but with more
intelligent children. Now, flattering as this

CHILDHOOD AND YODTH. 131

may be to tlie parents, it is thorouglily baneful
to tbe interest of the feeble-minded little one.
The most successful training is effected with
the child's equals ; in this way a healthy emu-
lation is established. Intelligent children will
not take part in the amusements and games
of feeble-minded ones, moreover, there is no
community of feeling or of interest. The out-
come of an attempt to train the feeble-minded
child with others more intelligent than himself
is infallibly to make his life solitary and to
accentuate the condition which it is of the
greatest importance to correct. I have seen
the relative of a nobleman, living in all the
luxury of a well-appointed country house, so
put aside by her sisters, junior as well as senior,
that she never ventured on a remark, and at
length lost speech. I have seen the same girl
transferred to a class of children like herself,
pass from monosyllables to thorough conversa-
tional language, amid the sympathy and com-
panionship of her compeers. Mothers of feeble-
minded children invariably think their children
more intelligent than any others of a like cate-
gory, and they only need the bias of medical
opinion to put off proper and effective aid until

132 MENTAL AFFECTIONS OF

it is too late. Being afraid of their association
with others of the same class, the parents either
send them to schools where their lives are made
wretched by teasing, and where they fall hope-
lessly behind, without the benefit of individual
skill, or the helpfulness of collective emulation ;
or the boy is relegated to a country vicarage
or Welsh farm, without any of the appliances
or agencies which can develop his best possi-
bilities. The first thing to be done is to rescue
the feeble one from this solitary life, to give
him suitable companionship, to place him in
a condition where all the machinery shall move
for his benefit, and where he shall be surrounded
by influences of art and nature calculated to
make his life joyous, to arouse his observation,
and quicken his power of thought. No one who
can speak from experience in the matter would
hesitate in saying that the companionship of
their equals in intellectual power provides just
the attrition which is desirable, — that the associ-
ation with their superiors condemns them to a
life of isolation which renders nugatory all
efforts for their improvement. The fear that
the association of a feeble-minded child with
feeble-minded children will exercise an injurious

CHILDHOOD AND YOUTH. 133

effect upon the growth of his intelligence is in-
correct and not based upon experience.

Dr. Ireland has very well said that " imbe-
cile children are no more injured by the
presence of others of inferior intelligence than
ordinary boys and girls are made childish by
the appearance of a baby in the house, — that
it is often, indeed, a great advantage for chil-
dren to get rid of the uniform and hopeless
inferiority in which they have hitherto lived,
and to find that they have equals with whom
they can interchange their simple ideas, and
who give them a ready sympathy, and even to
find that they have inferiors." How well I
remember one feeble-minded boy coming to me
and expressing his interest for another who
was crippled, and saying to me, " Doctor, what
a pity it is that that boy is lame, although he is
not quite right." If there was any effect from
the association it was that it begat a pharisaical
spirit rather than exercised a depressing influ-
ence. The position of the feeble-minded is
not always a very desirable one in the houses
of the wealthy. Too often his claims are lost
sight of, and the great aim is to keep his
existence a secret, while no kind of com-

134 MENTAL AFFEOTJONS OF

panionsliip is established between him and the
other members of the household. Moreover,
the claims of society and the presence of visitors
tend to make what little training there is desul-
tory and futile, and lead to his being consigned
to the care of servants in the less frequented
portions of the house, where his life must
necessarily be monotonous, uneventful, and
uninteresting. If such are the difiBculties
among the wealthy, how much more are they
intensified in the houses of the poor, where the
parents are making a desperate struggle for
existence, — where the afflicted little one uses
up the time and energy of one sane life ! How
can it be possible, with the arrangements of a
cottage, that anything tangible can be done to
rescue the child from a condition which is
deplorable in every aspect ? Is it not probable
that the mother, with her attention always
directed to this object of care and anxiety,
will propagate a neurotic race? Those who
have witnessed the transformation in chil-
dren who have been removed from squalid
cottages to a well-regulated institution, or have
seen their joyous return from luxurious homes
to their companions and their training, will be

CHILDHOOD AND YOUTH. 135

able to realise how trutliful is a motlier's ac-
count of her boy that : " When putting him to
bed the last night he was here he was smiles all
oyer, saying, ' Groing back to school to-morrow,
mother,' and he packed his own bag before I
could get to him in the morning, and could
hardly finish breakfast he was in such a hurry
to be off, and went away all smiles and delight."
It must always be kept in mind that the basis
of all treatment should be medical. Medical,
I mean, in an enlarged sense. Success can only
be secured by maintaining the patient in the
highest possible health. This is very well in-
dicated by the intellectual torpor which follows
or accompanies declension of health, and the
lessened intellectual vigour which is met with
in cold weather. I have referred to the hiber-
nation which occurs among many feeble-minded
children, and which has led me to notice that
their intellectual vigour is directly as their
external temperature. The pallor of the cine-
ritious portions of their brains, which is so
frequently met with, is suggestive of the neces-
sity of vigorously maintaining their nutritive
life. A very liberal dietary is of great import-
ance. It should contain a fair quantity of

136 MENTAL AFFECTIONS OF

nitrogenous elements, and be rich also in phos-
pliatic and oleaginous constituents. Green
vegetables are very essential, as in their absence
there is a great tendency to become scorbutic.
Care should be taken that farinaceous food, as
represented by the so-called corn flours, should
give way to the more plastic elements of nutri-
tion found in semolina, entire wheat flour, or
macaroni. Not only must the diet be sufficient
in amount and good in quality, it should be
exhibited in a form suited to their power of
mastication. Their bedrooms and sitting-rooms
should be spacious and well ventilated, and
especially well warmed.

The skin should be kept in healthy function
by frequent sponge and other baths, both
for the sake of the individual health, and for
the health and comfort of their associates.
The exhalation from the skin of feeble minded
children is something sui generis. It is of
great importance that their residence should be
on gravel soil, and with well-made walks, that
no opportunity may be lost for outdoor exer-
cise. Warm clothing is essential, to prevent as
much as possible the disastrous effects of
climatic changes. 1 have before referred to

CHILDHOOD AND YOUTff. 137

the relative frequency of phthisis to the ordi-
nary mortality. Dr. Fitch, of Elwyn, Pennsyl-
vania, in a very interesting paper, relates his
experience that over 50 per cent, of his deaths
were from disease of the lungs and air passages.
My own experience is that on a clay soil 64
per cent., while on a gravel soil 44 per cent.
of the mortality was from that cause. He also
relates, what is in conformity with my experience,
and in harmony with what I have been insist-
ing on, that there is always a remarkable immu-
nity from disease during the summer months.
Having placed our patient under the most favor-
able hygienic conditions, the special training
should be carried out with great enthusiasm.
Physical training must form an important part
of the education. The feeble muscles must be
nourished by calling into exercise their func-
tions, as well as by massage and by galvanism.
Simple automatic movements, which I have
referred to as being so common with the feeble-
minded, should be replaced by others which are
the product of will. We have to commence
with very simple ones, gradually making them
more complex. The want of co-ordination in
the muscular system is very characteristic of

138 MENTAL AFFECTIONS OF

the feeble-minded, and it is only by judicious
physical training that the mutiny of the muscles
can be overcome, and that purposeless acts can
be converted into voluntary efforts suited for
the wants of daily life. This training has to
be carried out in great detail so that every
voluntary muscle and every system of muscles
may be called eventually into action. In this
way the various acts of prehension, locomotion,
and mastication are taught, the tongue becomes
a willing agent, and the lips learn to retain the
saliva which before gave our patient a repulsive
look. I cannot enforce too strongly that little
progress is made in speech until we first attain
co-ordinated movements in the limbs. Finger
lessons are to precede tongue lessons. I always
remember the pinioned Frenchman who en-
treated that his arms might be freed because
he wanted to speak. Unless we succeed in
unpinioning the arms of our patients they do
not speak. It is to be remembered too that we
cannot bring into harmonious relation the
muscles and the will without improving the
physical quality of the brain and the other
nervous centres. By these means, too, we shall
have placed our patient in practical relation

CHILDHOOD AND YOUTH. 139

witli the external world and initiated reasoning
power.

The moral training is of great importance.
While his physical and mental powers are being
developed by hygienic and physiological pro-
cesses, he has to be taught to subordinate his
will to that of another. He has to learn obe-
dience; that right-doing brings pleasure, and
that wrong-doing is followed by its deprivation.
The affective faculties should be so cultivated
that the deprivation of the love of the teacher
should be the greatest punishment and its mani-
festation the highest reward. In this way in-
dications of untruthfulness, selfishness, obsti-
nacy, sensuality, theft, and unMndness to com-
panions are checked. Corporal punishment
should be strictly forbidden. The tact of the
teacher will be called into exercise in devising
the suitable reward or punishment. I have
seen a girl exhibiting violent obstinacy melted
into contrition and obedience by the threat of
the teacher that she would wipe from her face
the kisses she had given her the previous day.
In no case should the punishment interfere with
the hygienic treatment. Nothing is worse than
the deprivation of food for an offence. I have

140 ' MENTAL AFFECTIONS OF

seen a case of violent and uncontrollable temper
reduced to calm obedience by the administra-
tion of a basin of bread and milk. The moral
delinquency was the result of mental excitement
the outcome of defective nutrition.

The intellectual training must be based on a
cultivation of the senses. They should be
taught the qualities of form and the relation of
objects by their sense of touch ; to appreciate
colour, size, shape, and relation by sight; to
understand the varieties of sound when ad-
dressed to the ear ; the qualities of objects by
their taste and smell. The lessons should be
of the simplest kind at first and gradually cumu-
lative. Nothing is to be left to the imagination.
The concrete must be taught, not the abstract.
In this way we give them the basis from which
their reasoning and reflective powers can be
developed. Synchronously with this we make
use of the physical powers we have cultivated.
They should be taught to dress and undress.
They should be trained to acquire habits of
order and neatness, to use deftly the spoon or
the knife and fork; to walk with precision and
to handle with tact. The defective speech is best
overcome by a well-arranged plan of tongue

CHILDHOOD AND YODTH. 141

gymnastics, followed by a cultivation of the
purely imitative powers, teaching at first mono-
syllabic sounds wbicb have concrete representa-
tives. The use and value of money where shops
are not accessible is best taught by a plan I
devised of instituting a shop furnished with the
usual appliances of sale. One patient acted as
the customer and another as the trader. In this
way a purchase was effected and the whole
transaction of buying, weighing, calculating,
and paying, with the reception of change, was
made under the criticism of the assembled class.
All these belong to school instruction.

It is desirable, however, to supplement the
house and school by gardening and farming
operations ; by the lathe, the fretwork machine,
the carpenter's bench, and, for the more advanced
in education, the printer's shop. For girls.
Kindergarten occupations and the various
elegancies of needlework may be the outcome
of persevering endeavours, while music and
dancing may for all alternate with dramatic
entertainments, which are most useful in appeal-
ing both to the eye and the ear. Care should
be taken that the physical should interchange
with the intellectual training. It is of the

142 MENTAL AFFECTIONS OF CHILDHOOD.

greatest importance that the teacher should keep
clearly in view that his primary object is to make
the pupil self-helpful, and, as far as possible, a
useful member of the community ; in this way
more is done than by any other means. Mere
memoriter knowledge is of little value ; every-
thing which makes him practically useful makes
him proportionately happy.

But I am warned that my allotted time has
expired. Methinks medicine of these later days,
which has signalised her march by numerous
victories, has had no more beneficent result than
has been achieved by the enthusiasm of such
men as Howe, Seguin, Wilbur, Knight, and
Oonolly of the past, and by those still living
who are followers, it may be at a reverential
distance, in the work of rescuing from oblivion
and neglect a class who appeal to our tenderest
sympathies and our most affectionate regards.

. ACCOUNT OP A CASE

IN WHICH THE

CORPUS CALLOSUM AND FORNIX
WERE IMPERFECTLY FORMED

AND THE

SEPTUM LUCIDUM AND COMMISSURA
WEEE ABSENT.

' Trans, of Eoy. Med. and Chir. Soc./ 1861.

The medical literature of examples of defective
commissures of tlie brain comprises so few-
cases, and of these the life-history is so imper-
fect, that I need no apology in placing the
records of another before the members of this
Society. The question has often been proposed
to me, what relation idiocy bears to these arrests
of development. At an early stage of my
inquiry into the pathology of idiocy, I was pre-
pared to meet with many cases characterised by
the heading of this paper, but on further investi-
gation found that, with the exception of deficient

144 DEFECTIVE CORPUS CALLOSUM.

commissura mollis, absence or defect of the
larger commissures of tlie brain occurred but
seldom. Among fifty brains of idiots which I
have dissected , the following is the only example
of this nature.

That idiocy frequently depends on defective
commissural connection my present experience
does not support ; but, on the other hand, that
the absence of such connection may not occa-
sionally be a cause of this calamity is, I appre-
hend, a question suh judice.

Mr. Paget, in the twenty-ninth volume of
your ' Transactions,' has so ably generalised on
the cases at that time on record, that there is
little to be done beyond adding to the facts illus-
trating this interesting subject.

The case to which I beg leave to call your
attention, is that of A. B — , a boy aged nine
years at the time of his death. He had pre-
viously been under my daily observation for
two and a half years. He was the first-born of
three children ; the second, a boy, is also
idiotic ; while the third and youngest, a girl, is
healthy and intelligent. The respective ages
of his father and mother, at the time of his
birth, were twenty- six and twenty- seven years ;

DEFECTIVE CORPUS OALLOSUM. 145

there was no consanguinity between them.
There is no history of mental disease, or of any
such defects as club-foot, hare-lip, cleft palate,
&c., in either branch of the family. The
mother's brother died of phthisis, but it was
not thought to be owing in any way to consti-
tutional predisposition. The mother, anteriorly
to her marriage, had suffered intense pain in
the left side, accompanied by hysteria ; subse-
quently to her marriage, and during the preg-
nancy which speedily followed, there was no
diminution, but rather an increase, of these
sufferings. The pregnancy was attended by
violent vomiting; and the pain in the side
becoming more and more insupportable, opiates
were largely resorted to for its relief. About
this time Sir Benjamin Brodie was consulted,
and his written opinion expresses the belief that
she was suffering from renal oxalate-of-lime
calculus. There were no unusual circumstances
during parturition.

At five years of age the boy was received into
the Asylum for Idiots at Earlswood. He was
then a fair and delicate child, three feet three
inches in height, fifty-three pounds and a half
in weight ; the shape of his bead was oval, the

10

146 DEFECTIVE COE.PUS CALLOSUM.

circumference above tlie eyebrows eighteen
inches and five eighths, length between the
eyebrows and occipital protuberance eleven
inches and three quarters, width of forehead
four inches and a half. At this time he could
stand alone, but was unable to walk ; he was
fed with a spoon, as he had no notion of mastica-
ting, and it was necessary for his nurse to con-
vey the food to the fauces in order to excite
the reflex act of deglutition. He could not
speak, and was very spiteful. His habits were
dirty, and this was augmented by frequent
diarrhoea. When seven years old he was able to
walk, though feebly, and was placed in the
infant class for training and instruction. At
nine, the period of his death, he could walk and
run, his spiteful habits had been overcome, he
was mild and tractable, and exhibited much
fondness for his younger brother. He was
timid, and afraid of certain toys, did not play
with other children, and found most amusement
in looking at a picture scrap-book. He was
fond of listening to music ; had little or no
power of imitation. Although great pains were
taken to instruct him, he could scarcely be said
to have learned anything. He would in some

DEFECTIVE COEPDS CALLOSUM, 147

measure go through simple exercises in drilling
at command, but could not be taught to throw
a ball with any aim. There was no want of
co-ordination in his movements, and no dimi-
nution of sensation ; his habits had become
moderately correct ; he was able to feed him-
self with a spoon, the meat having been pre-
viously minced, and with much difficulty he was
taught to raise a cup to his mouth. He remem-
bered his father and mother ; on seeing any lady
in black, the colour usually worn by his mother,
he would approach, and after examination would
say, " No, mamma ! no !" which, with the word
" me " when he wanted anything, was the full
extent of his powers of utterance. He had no
vivacity, and his extreme pallor was remarkable.

His physical health was far from good ; he
was never long free from either strumous oph-
thalmia, eruptions at the nasal and oral orifices,
thecal abscesses, or diarrhoea ; but he had never
been subject to convulsions or epileptic fits. He
died from pneumonia on the right side.

A post-mortem examination was made thirty-
three hours after death. The right lung was
hepatized throughout, except at its anterior
margin. Several of Peyer's glands in the ileum

148 DEFECTIVE CORPUS CALLOSUM.

were enlarged and congested. The large intes-
tine extremely congested throughout. The
testes had descended into the scrotum, but were
small ; the pubes was sparsely covered with hair.
The other organs were healthy.

The calvarium was of normal thickness, but
somewhat unsymmetrical ; there were granular
patches in the arachnoid on both sides of the
longitudinal fissure, and between these and the
dura mater slight adhesions. The encephalon
weighed two pounds eight ounces avoirdupois ;
the cavity of the arachnoid contained about two
ounces of straw-coloured serum; the membranes
and sinuses normal. The antero-posterior
diameter of the cerebrum was six and a half,
its width five and a half inches ; the width of
each hemisphere measured across the anterior
lobe, in front of the remnant of the corpus
callosum, two and a quarter inches. The antero-
posterior diameter of each hemisphere of the
cerebellum was two and a quarter, its entire
width three and a half inches.

On making sections of the cerebrum and cere-
bellum, there was nothing noticeable respecting
the size, form, arrangement, or colour of the
convolutions. On the first removal of the

DEFECTIVE CORPUS CALLOSTJM. 149

enceplialon from tlie cranium, it was noticed
that, on being placed in its natural position,
the hemisplieres separated to an unusual extent,
without bringing into view the great commissure
of the brain, but displaying, instead, the velum
interpositum. Anterior to the velum, and on the
same plane, was exposed, on forcibly separating
the hemispheres, a narrow band of medullary
structure. A horizontal section of both hemis-
pheres, so as to display the interior of the lateral
ventricles, was then made, and the velum inter-
positum removed. The brain was in no part of
its structure deficient in cohesion ; the posterior
cornu of each of the lateral ventricles was
enlarged, and contained about half an ounce of
straw-coloured serum each. The small hippo-
campus on each side was rather large ; the
taenia semicircularis very fully developed. At
this stage of the dissection no remnant of the
fornix could be discerned ; there was positive
absence of any septum lucidum. The third
ventricle was exposed, but no middle commis-
sure could be discovered ; the pineal gland occu-
pied its usual position between the lobes of the
corpora quadrigemina, all which structures were
of normal size and appearance. At the ante-

150 DEFECTIVE CORPUS CALLOSUM.

rior boundary of the third ventricle there was
the before-mentioned medullary band, which
was regarded as the representative of the corpus
callosum, but occupying a much lower plane
than the normal position of the commissure.
It presented, both anteriorly and posteriorly,
crescentic, thinned margins, and measured at
its narrowest part, which was slightly to the
left of the mesial line, one third of an inch. A
section was then made through both hemi-
spheres on a level with the transverse band.
The optic thalami were unusually flattened, and
their inner surfaces indicated that the soft com-
missure had never been present. There was a
marked absence of the peduncles of the pineal
gland. The third ventricle presented on its
floor the usual structures, and at its anterior
part could now be seen the anterior pillars of
the fornix ascending at slight angles, but widely
separated throughout. Beneath the posterior
margin of the transverse band they made a
sudden bend, and, passing outward and back-
ward over the upper surface of the optic thalami,
terminated in the descending cornua of the
lateral ventricles as the teenise hippocampi, the
tsenise, however, being narrower than usual.

DEFECTIVE OOEPUS OALLOSUM. 151

The optic commissure at the floor of the third
ventricle was strongly marked, and the lamina
cinerea interleaved between it and the anterior
commissure, where it terminated. The ante-
rior commissure was well defined, and above it
an interval of two lines occurred between it and
the transverse band. The inner surfaces of the
anterior lobes of the cerebrum were separated
inferiorly as far as the anterior commissure ;
and the parts of them into which the knee and
reflected portion or rostrum of the corpus callo-
sum are usually inserted were covered with
convolutions such as are common to other parts
of the cerebral surface. The band or rudiment
of corpus callosum was situated opposite the
widest portion of the corpora striata; its anterior
edge being two and one twelfth inches from the
anterior margin of the cerebral hemispheres,
and its posterior border being four and one
twelfth inches from the posterior margin of the
hemispheres. It did not exceed one sixteenth
of an inch in thickness at any part of it, and its
fibres spread out anteriorly and posteriorly on
reaching the hemispheres. It will follow from
this description that there was no representative
of the genu or of the reflexed portion of the

152 DEFECTIVE CORPUS OALLOSUM.

corpus callosum ; that the body of the fornix,
septum lucidum, and its fifth ventricle, and the
soft or middle commissure, were entirely absent ;
and that there existed no communication
between the lateral representatives of the
fornix ; moreover, that these had no connection
with the posterior diverging fibres of the trans-
verse band, and consequently that not even the
analogue of a septum lucidum was present.

Mr. Paget, in the twenty-ninth volume of
your ' Transactions,' has grouped together with
his own case others related by Eeil, Mr. Solly,
and Mr. Chatto, and has made some important
physiological deductions. The case related by
him was " not remarkable for any excellence or
great defect of mind." In Mr. Solly's, the boy,
although *' boobyfied," could read, and selected
as his favourite reading religious books. Reil's
case, a woman, was of dull intellect, but could
go errands in the village. Mr. Ohatto's patient
lived only twelve months.

In comparing the case which has been here
detailed with those referred to by Mr. Paget, it
would, at first sight, appear to stand opposed
to the conclusions at which he arrived, and to
support the view that the corpus callosum is

DEFECTIVE OOEPUS OALLOSUM. 153

necessary to the possession of the average
power of tlie human mind. But this opposition
may be only apparent ; for it is a circumstance
worthy of special regard in instituting a com-
parison, that while in the three above-named
examples the soft commissure was present, in
the one which I have brought forward it was
entirely absent. Moreover, in Mr. Solly's case,
the soft commissure was " wide and thick," and
in Mr. Paget' s it was inordinately large, measur-
ing six tenths of an inch from before backwards,
and being also thicker than usual.

How far the presence of extra large, middle
commissures compensated for other deficiencies
in the former cases, and how far its absence
was the cause of the extreme mental deficiency
in the present instance, I shall not now discuss.
I will only say that my researches hitherto lead
me to attach a physiological importance to the
soft commissure which previous observers have
not recorded.

ON THE

CONDITION OP THE MOUTH IN IDIOCY.

The ' Lancet/ vol. i, 1862.

The opinion wliicli has been formed, both in
and out of the profession, in reference to idiocy,
has arisen more from the representations of
poets and romance- writers than from the deduc-
tions of rigid observation. The popular novelist,
in this as in other cases, seizes on the charac-
teristics of some exaggerated specimen, pour-
trays them by the aid of a vivid imagination,
and henceforth the exaggeration becomes the
type of a species in the minds of men. The
term idiot has thus become synonymous with
the most degraded condition of humanity only
— with a creature incapable of being influenced
by moral or physical treatment, and. separated
by an immense gulf from the remainder of man-
kind. It has arisen, in no small degree, from
the existence of this opinion, that until within

CONDITION OP THE MOUTH IN IDIOCY. 155

a comparatively recent period, so few efforts
liave been made to ameliorate the condition of
idiots. In too many cases they have been
neglected or allowed to be influenced for evil,
regardless of the fact that they might be equally
impressed for good. Independently of the
benefit that can be effected for these unfortu-
nate sufferers, the benevolent efforts on their
behalf have furnished an opportunity for an
investigation into their physical and psychical
life before unattainable.

The condition of the idiot is not simply one
of mental alienation. It frequently presents
also grave physical deterioration; and this
physical alteration is as much a test of idiocy
as is the low condition of mental power. In a
community such as that of the Earlswood
Asylum, there is to be found every variety of
imbecile mind. In fact, just as in the outer
world there is a graduated series from the most
commonplace intellects, — who are " the hewers
of wood and drawers of water," — up to the
giant minds that leave their impress on the age
in which they live ; so is there amongst an
imbecile population a gradual shading in an
inverse direction — from the youth who might.

156 CONDITION OP THE MOUTH IN IDIOCY.

if lie tad property, become tlie subject of
inquiry before a Master in Lunacy, to one who,
with every means of communication with the
external world, except feeling, closed, vegetates
in impenetrable mist. In such a community
one can perceive the grades of physical condi-
tion accompanying the mental phases ; and a
study of the physical anomalies becomes as
interesting and important as that of the psycho-
logical state. When contemplating so large a
number as that which Earlswood shelters, one
is able to set some of the members aside into
natural groups, by simple reference to their
physical state, and to predicate from that state
what will be their probable future mental
improvement.

There is scarcely an organ in the body but
may be found gravely altered in idiots : the
circulation and respiration are abnormal; the
skin exhibits perturbed functions ; defective
innervation, lesions of motility and nutrition,
are abundantly met with ; the bodily conform-
ation is often of an aberrant kind. Regard
therefore should be paid, in all cases of dia-
gnosis of idiocy, to the physical condition as
confirmatory of any opinion based on purely

CONDITION OF THE MOUTH IN IDIOCY. 157

psychological data. It is in this way one is
enabled to differentiate an idiot from a simply
backward or ill- regulated child.

It is from the conviction of the importance
of a study of the physiological manifestations
of idiocy, that I have been induced to devote
no small portion of time to an investigation
into the structure and functions of the various
organs seriatim amongst idiots and imbeciles.
I purpose in the present paper giving some of
the results of my observations of the feeble-
minded, in reference to the condition and con-
formation of their mouths. Characteristic as
is this region of various transitory mental phases
amongst the sane, does it bear the permanent
impress of a state in which the mind has failed
in attaining its normal condition ? If so, what
is the nature of the impress ? Does any value
attach to the conformation of the mouth as
confirmatory or otherwise of a state of mental
incapacity ? These are some of the questions
we have to solve.

I may premise that these observations have
been made during the past year, without refer-
ence to any recent legal inquiry, and extend
over 200 cases, Avhich have been taken, with-

158 CONDITION OF THE MOUTH IN IDIOCY.

out any special selection, from a larger number.
Not one on the list would in his present con-
dition be able to manage his own afiairs, or be
legally held to be responsible. Many of them,
however, are susceptible of considerable culture,
are affected by the amenities of life, write letters
to their friends, make small purchases, and form
friendships. Several perform mechanical work
with system and order. One, although posses-
sing very little judgment, has been taught
French and Latin, and reads these languages as
well as ordinary schoolboys. Some few possess
extraordinary memories and special aptitudes.
146 were males, and 54 females. Their ages
ranged from seven to thirty-six, and the follow-
ing table gives the numbers at each age last
birthday : —

No.

Age.

No.

Age.

No.

Age.

2

at 7 .

. 14

at 16

.. 5

at 25

4

„ 8 .

. 18

„ 17

.. 1

„ 26

2

„ 9 .

.. 10

„ 18

.. 3

„ 27

4

„ 10 .

. 14

„ 19

.. 2

„ 28

10

„ 11

. 18

„ 20

.. 1

„ 29

13

„ 12 .

. 7

,. 21

.. 3

„ 30

11

„ 13 .

. 12

„ 22

.. 2

„ 33

12

„ 14 .

.. 9

„ 23

. 1

„ 34

17

„ 15 .

.. 3

„ 24

.. 2

» 36

CONDITION OP THE MOUTH IN IDIOCY. 159

Or ranged in decennial periods — below 10
years, 8 ; from 10 to 19 inclusive, 123 ; from 20
to 29, 61 ; from 30 to 39, 8.

Palate. — Amongst tlie 200 cases included in
this inquiry, 82 possessed palates inordinately
arched, and with this increased arching were
noticed various abnormalities. In some the
palate was unsymmetrical, the two sides having
different degrees of concavity, or one side
plane, and the other concave. In 34 the
palates were excessively arched, approximating
to the appearance of the roof of a house, and,
with this extreme angularity, was great narrow-
ness. Excessive arching of the palate occurred,
therefore, in 58 per cent. Excessive flattening
of the palate was observed in 4 cases. In 34
cases, or 17 per cent., the palate had a very
prominent antero-posterior ridge or keel, corre-
sponding to the line of approximation of the
palatal bones. In 7 the palate bones did not
meet, leaving a sulcus between them, the
mucous membrane being, however, continuous.
There was no instance of the ordinary cleft
palate, and I may remark that in an exami-
nation of nearly 600 idiots, I have failed in
meeting with an example of that deformity. In

160 CONDITION OF THE MOUTH IN IDIOCY.

several the hard palate extended but a short
distance posteriorly, from defect of the palatal
process of the superior maxillary bone and
entire absence of the palatal process of the
palate bone, and in all these cases the velum
palati was unusually flaccid. In the majority
of cases there was marked narrowness of the
palate. The following table represents the
measurements in 24ths of an inch of the space
between the posterior bicuspid teeth of opposite
sides : —

No.

2
1
3
2

13
10

Distance.

No.

Distance.

No.

Distance

In.

In.

In.

. 11

n+ 2 3

13

at

l2\

18

)) -^4

. 24

„ 1 ..

9

l2\

19

» 2¥ ••

. 37

» hk ■■

1

1/4

SO

. 25

1 2

>> -'■24 ••

6

1^

21
»> 24

. 23

M lA ..

. 3

HI

2 2
'> '24 ■

. 17

1 ■*

3> -'■2 4 ■•

. 1

Iff

It will be observed that 33 per cent, do not
exceed 1 inch, and that 62 per cent., while being
more than 1 inch, do not exceed 1^ inch ;
whereas the normal average has been stated to
be IJ inch. It is worthy of notice that these
numbers hold no direct relation to the age or
stature of the patients examined. Thus, in a

CONDITION Of THE MOUTH IN IDIOCY. 161

youth 22 years of age and 6 ft. 1 in. in height,
SO narrow is the palate that there is only 1-^^
inch between the bicuspids, and only ^ inch
between the opposite gums at their widest
interval. The lowest measurements occurred
in a boy and girl, the boy 12 and the girl 13
years of age. Neither is there a direct relation
between the width of the palate and the cranial
capacity ; for in a microcephal, whose palate
was If inch wide, the internal canthi of the eyes
were f f inch distant from one another ; while
in a macrocephal whose palate was ff inch
wide, the distance between the internal canthi
amounted to 2 inches.

Teeth. — The principal characteristics of the
teeth in idiots are, that the period of the first
dentition is delayed, the second dentition con-
siderably postponed, and that they undergo
very general and rapid decay. In many cases
the anterior surface of the incisors presents a
honeycombed appearance, but in no one instance
have I observed those special characters which
have been well shown by Mr. Hutchinson to be
significant of congenital syphilis. In a large
number of cases they are developed irregularly,
are crowded, and the canine occupy a different

11

162 CONDITION OF THE MOUTH IN IDIOCY.

plane from the otlier teeth, — all these irregu-
larities resulting from the imperfect develop-
ment of the superior maxillary bone. In 6
cases, or 3 per cent., the upper incisors pro-
jected to such an extreme degree as to produce
grave deformity. In 7 cases the teeth of the
lower jaw were in advance of those of the
upper.

Tongue. — The most prevailing character no-
ticeable in the tongue of idiots is the hypertrophy
of the fungiform papillae. Undue prominence
of the papillae was observed in 101 instances.
In several there is a marked want of co-ordina-
tion in the movements of the tongue, so that
the patient, although endeavouring to comply
with the request, is unable to protrude it. This
condition is usually associated with an absence
of general co-ordinated movements, and in the
improvement which is effected by treatment it
is usually the most persistent derangement of
motility. In 16 cases the tongue presented a
soddened appearance and exhibited deep trans-
verse furrows on its dorsal surface ; in all these
patients one is able to trace a marked physio-
logical and psychological agreement, and so
much do they resemble one another in these

CONDITION OP THE MOUTH IN IDIOCY. 163

respects that they might readily be taken for
members of the same family. Inordinate size
occurred in 12 instances, and in almost every
case was associated with defective power of
articulation. In 2 the tongue was unusually
lonsr ; 33 were mute : 16 semi-mute. In 83
the speech was indistinct. In 62 the speech
was fair. Stammering was observed in 4.

Tonsils. — One cause of the peculiar speech
prevailing among idiots is the condition of the
tonsils. These observations for the most part
were made in the summer, when the tonsils
were not likely to be rendered worse than their
usual condition by climatic influences. In 30
instances they were injected, in 17 slightly
enlarged, in 79 considerably enlarged, and in 5
so much increased in size as to interfere with
deglutition and respiration.

Mucous membrane, ^c. — Besides the injection
of the mucous membrane of the tonsils which
has been noticed, other regions of the oral
cavity are liable to this condition. The velum
palati, uvula, and pillars of the pharynx were
found to be thus characterised in 27 instances.
The posterior wall of the pharynx was observed
to be marked by considerable vas<5ular injection

164 CONDITION OF THE MOUTH IN IDIOCY.

in 33 cases, and in 6 the mucous membrane
had assumed a granular appearance. The
buccal and labial glands were generally hyper-
trophied, and the salivary glands were fre-
quently enlarged. In 11 instances the sub-
lingual gland was greatly enlarged. The uvula
was elongated in 14 cases, bifid in 2, very short
in 1, and entirely absent in 1. The lips were
hypertrophied in 2. Owing probably to the
abundant supply of fresh vegetables with which
the patients are provided, I only found one
case in which the gums were swollen and
tumid.

Slavering, — The flow of saliva from the mouth
is universally associated in the popular mind
with the condition of idiocy. The slavering
may vary in degree. It may occur only at
periods of excitement, and at meal times, or
with scarcely any intermission throughout the
day, producing in severe cases excoriation of
the chin. Amongst 325 cases which I have
examined, I find 72, or 22 per cent., in which
this habit was noticed. Of these, 28 slaver to
a slight extent, 17 rather more so, and 26 in an
aggravated degree. This peculiarity depends,
I believe, on two or three causes — 1st, the in-

CONDITION OP THE MOUTH IN IDIOCY. 165

creased secretion of saliva ; 2nd, the deformed
condition of the mouth ; 3rd, the want of co-
ordinated movements in the muscles of the
tongue ; and 4th, the absence of tonicity in the
labial muscles. Seeing that slavering exists in
22 per cent, of imbeciles, the question may-
arise — Is it confined to this section of the com-
munity ? I am not prepared to say that it is
never associated vsrith mental vigour; but I
believe that, excluding childhood, old age, dis-
ease of the mouth and neural lesions, slavering
is very rarely unconnected with mental imbe-
cility. Moreover, I have examined with refer-
ence to this question 1000 persons, who are
doing the everyday work of the world, without
meeting with a single example.

Summary. — We have thus seen that idiocy is
not simply a cerebral lesion ; that it carries
with it marked physical deviations, of which I
have shown conspicuous examples in the mouth ;
narrowed, arched, and unsymmetrical palates ;
tardily developed, irregular, and rapidly decay-
ing teeth ; a hypersemic condition of the mucous
membrane and glands; elongated uvulas and
hypertrophied tonsils ; large, enervated, and
rugous tongues, deficient in co-ordinated move-

166 CONDITION OF THE MOUTH IN IDIOCY.

ments and in their special function ; saliva
secreted inordinately, and retained inconti-
nently. Such, are some of the characteristics
of a class, in which mental vigour is in abeyance,
which should be taken in connection with the
psychological state in diagnosis, and inculcate
the doctrine that the psychical condition of
these unfortunates should be specially sought
to be ameliorated by an improvement of their
physical condition.

ON

POLYSARCIA AND ITS TREATMENT.

« London Hospital Reports,' 1864. *

The term polysarcia has been so long accepted
as a designation of that condition of the body, in
which the purely adipose constituents are devel-
oped in excess, that I am induced to employ it,
although its Hteral significance is not strictly
in accordance with the pathological state.

The history of Medicine contains numerous
instances of extraordinary obesity, and an im-
mortality attaches to some names, solely on
account of special aptitude for the development
of fat. It is not in reference to such excep-
tional examples as some of the earlier records
of medicine unfold, that the practitioner is
likely to be consulted, but the cases are not
infrequent in which his aid may be solicited in
mitigating the inconveniences which excessive
adipose development entails.

168 POLYSAROIA AND ITS TREATMENT.

The sufferers from this disease are found
more frequently among those on whom fortune
has smiled, whose incentives to physical exertion
are in abeyance, while the inducements of the
table are in excess. Nevertheless among the
out-patients of the hospital, I have noticed
several cases, in which polysarcia has been the
cause of a variety of subjective symptoms which
have made life wretched. The subjects have
been for the most part women who had passed
the climacteric period. They have resorted to
the mental solace which alcoholic potations
could afford, and their diet, though poor, has
been of the kind calculated to induce this
state.

Dr. Flemyng, in a paper read before the Royal
Society in 1757, regarded corpulency as caused
either by the introduction of too much oil in
the food, or by the over-largeness of the cells,
in which it is deposited — or by a crasis of the
blood allowing the oily particles to be strained
off too easily — or, lastly, by a deficient evacu-
ation of oil already taken in and separated from
the blood.

His remedies were addressed either to increas-
ing the evacuation by the bowels, the sweat-

POLYSAHGIA AND ITS TREATMENT. 169

glands, or the renal organs. Diuresis was his
principal hope, inasmuch, he said, as " the
animal oil is carried out of the body in the
urine." The diuretic he selected was soap, from
his supposing it to have the property of " besides
increasing the quantity of urine, at the same
time rendering the animal oil more mixible with
the watery vehicle of the blood."

Darwin, in his ' Zoonomia,' recommends
aerated alkaline water, from an idea of its render-
ing fat more fluid. Dr. Cullen was of opinion
that " the diet must be sparing, or rather, what
is more admissible, it must be such as affords
little nutritious matter ; it must, therefore," he
said, " be chiefly or almost only of vegetable
matter, and, at the very utmost, milk."

Dr. Brown argues "that as animal food is
the principal noxious power, the quantity should
be reduced, and more exercise taken."

Dr. Fothergill states that " a strict vege-
table diet produces exuberant fat more certainly
than any other means I know." He enjoins,
moreover, " an abstinence from animal food, so
far as the patient's health, situation, and man-
ner of life, will admit of it." Dr. Bright has
advised iodide of potassium with the view of

170 POLTSAEOIA AND ITS TEEATMENT.

giving tone to tlie absorbents. Alkalies, from
their power of saponifying fats, and thus rend-
ering them more miscible, have had their advo-
cates.

More recently, Dr. Duchesne-Duparc has
spoken highly of the effect of the extract of the
fucus vesiculosus, stating that it increases the
appetite, diuresis, and emaciation.

The following case of polysarcia, which has
been for some time under my observation, has
given me an opportunity of testing the value
of some of these remedies which have been
recommended, and of proving the superior effi-
cacy of that which I believe to be the true
physiological mode of treatment.

E. 0 — , a girl of healthy parentage, and born
in the county of Norfolk, became an inmate of
the Asylum for Idiots at Earlswood, in the year
1850, at the age of thirteen years. From notes
taken by Dr. Foreman at the time of her admis-
sion, I learn that she was congenitally of feeble
mind, was four feet four inches in height, and
weighed in her clothes 113 lbs. ; her size at that
time attracted observation, as it is noted, " she
is enormously stout, cellular tissue everywhere
more than usual." Her diet was not much

POLTSAEOIA AND ITS TEBATMENT.

171

restricted, and slie always appears to have been
voracious in appetite. In January, 1857, Dr.
Maxwell added to the above notes that she was
still the same height, but weighed 151 lbs., and
up to. that time had not menstruated. She came
under my treatment in November, 1858, when
I found her indulging in a large mixed diet,
with excess of vegetables, and taking very little
exercise, and her size was steadily increasing.
Her height was still the same, and her weight
196 lbs. Her unwieldy size rendered exercise
difficult. From inquiries made of her friends,
I found there had been no such instance of
obesity among the relatives of her progenitors
— that she had been delicate and thin up to
seven years of age.

Her diet was restricted to the following scale,
which was accurately weighed for each meal : —
Breakfast, six ounces of bread; one third
ounce of butter ; half-pint of milk-and-water.
Dinner — four ounces of meat (weighed, when
cooked, and free from bone) ; eight ounces of
potatoes ; two ounces of green vegetables ; six
ounces of pudding ; half-pint of water. Supper
—six ounces of bread; one third ounce of
butter ; half -pint of milk-and-water. (The milk-

172 POLYSARCIA AND ITS TEEATMENT.

and-water was a mixture of one third new milk
and two thirds water.) "Walking exercise was
enforced, and she was required to turn the
handle of a large mincing-machine one hour
a day.

My note-book states that in January, 1862,
she remained the same height (four feet four
inches), but had increased in weight. She was
then 210 lbs. when weighed in her night-dress,
and measured, round her waist, fifty-five inches.
Her feet and hands remained small, and con-
trasted remarkably with the appendages they
terminated. She had no hair in the axillse, and
scarcely any on the pubis. Although twenty -
five years of age she had never menstruated, nor
did she exhibit the slightest sexual instinct. She
was now able to walk slowly, but with difficulty,
and when she fell, was unable without assistance
to regain the vertical position. She suffered from
dyspnoea, and her breathing at night was
attended by so much noise that the occupants
of the same room were much disturbed thereby.
Moreover, the difficulty she had in moving from
her bed bad induced dirty habits, which added
much to the wretchedness of her life. It was now
difficult to induce her to take any exercise, and

POLYSAKOIA AND ITS TREATMENT. 173

she was scarcely seated in a chair for a minute
without falling asleep. Although imbecile in
mind, her obesity was a mental trouble to her,
and she was ready to enter into any plan for
diminishing her size.

Being desirous of ascertaining the effect of
medication simply, the same diet was continued,
and iodide of potassium, in doses of two and a
half grains, given three times a day, for a period
of six months, without any diminution of size.
Her health continued unaltered. The only effect
produced was a cessation of the development of
fat, which had been constant for the past twelve
years.

The diet remaining the same, solution of
potash was given three times a day in doses of
ten drops, gradually increased to half a drachm,
over a period of seven months. Under this
treatment her health became deteriorated, pre-
senting symptoms of anasmia, and her weight
oscillated around fifteen stone, sometimes a few
pounds more, sometimes as many less.

When the alkali was discontinued, on Feb-
ruary 13th, 1863, she weighed in her night-
dress 206 lbs. A diminution was thus eftected
of 4 lbs. after seven months' exhibition of

174 POLTSAECIA AND ITS TREATMENT.

caustic potash. Still continuing the same
mixed diet, the extract of fucus vesiculosus
(prepared by Messrs. Kew and Co., of Regent
Street) was given in doses of half a drachm
three times a day until April 30th, when she
weighed 203 lbs.

The effect of the fucus was to promote
diuresis, as indicated by an increased number
of wet beds, and a diminution of weight at the
rate of four ounces and one third per week.
Her general health had improved, and she was
much less anaemic than when she discontinued
the potash.

On April 30th, in conformity with a pre-
viously arranged plan, I discontinued all medica-
ments, and placed her on very rigid animal diet.
Her breakfast consisted of five ounces of cold
roast meat, free from fat, and half a pint of tea,
with very little milk, and no sugar (no bread).
Dinner — six ounces of hot roast meat, free from
fat, two ounces green vegetables (no potatoes
or bread), half a pint of water. Supper the
same as breakfast. In order to induce her
compliance, she had one ounce of sherry wine,
and occasionally a baked apple with her dinner,
and to prevent the possibility of her obtaining

POLTSAEOIA iLND ITS TEEATMENT. 175

any food from others, strict supervision was
exercised.

After slie laad been subjected to tbis diet for
a week sbe bad sbgbt febrile disturbance, and
for three days took one quart of beef -tea a
day, made from one pound of beef. Sbe then
returned to ber meat diet, which was continued
without intermission until August 29th, when
she weighed 175 lbs. The effect of this diet
was to improve her general health and physical
power. She was enabled to run, and she took
walks with pleasure. The dyspnoea had dis-
appeared, and her clothes had to be altered to
suit her diminished form. Her loss of weight
had been at the rate of one pound and three-
quarters per week.

Wishing to ascertain whether thefucus vesicu-
losus would influence the system when a purely
animal diet was used, half a drachm of the
extract was now given three times a day, while
the diet was restricted to sixteen ounces of
meat. This was continued until November
14th, when she was attacked by scarlet fever ;
her weight had receded to 153 lbs., the diminu-
tion having been at the rate of one pound
thirteen ounces one third per week, or one

176 POLYSAROIA AND ITS TREATMENT.

ounce one third per week more than when the
meat was given without the fucus. During the
attack of scarlet fever and the subsequent con-
valescence, the diet was beef -tea with bread ;
and on this diet, at the end of four weeks, her
weight remained without alteration. On Decem-
ber 12th she returned to meat diet, substituting,
however, fifteen ounces for sixteen ounces per
diem. This has been continued to the present
time (January 15th, 1864) ; her weight is now
147 lbs., and the measurement round the waist
has diminished from fifty-five inches to thirty-
seven inches. Her general health is good, and
the restricted diet has not been attended by
any inconvenience. The following tables will
give, in a condensed form, the results : —

Mixed diet, unrestricted in

amount
Mixed diet, restricted

amount
Mixed, restricted diet,

Iodide of Potassium .
Mixed, restricted diet,

Liquor Potassse . . . — . . 2^ oz.
Mixed, restricted diet, and

Fucus Vesiculosus . . — . • 41- oz.
Purely meat diet, witliout

medicine . . . . — , . 28 oz.
Purely meat diet, with Fucus

Vesiculosus . . . — . . 29i oz.

Weekly Increase

Weekly Decrease

in weight.

ill weight.

in

7i OZ.

m

1| oz.

and

nil

nil.

and

POLYSAECIA AND

ITS TREATMENT. 177

Date.

Age.

Weight.

28tli Feb., 1850 .

13 .

. 113 lbs.

Jan., 1857 .

20

. 151 „

Nov.. 1858 .

2U

. 196 „

Jan., 1862 .

25

. 210 „

ISth Feb., 1863 .

. 26

. 206 „

30tli April —

. —

. 203 „

22nd Aug. —

. 26i

. 175 „

14th Nov. — .

—

. 153 „

15th Jan., 1864 .

27

. 147 „

It is only by returning to the views and
opinions of medical authorities a century ago
that we can duly appreciate the vast service
chemistry has rendered physiology, and, m-
directly, practical medicine. The influence of
respiration in removing carbonaceous materials
from the blood, and the possibility of the pro-
duction of fat from farinaceous and saccharine
bodies, are so familiar to us that we wonder at
the absence of knowledge on these subjects
displayed by the older writers. They all insist
on a non-nutritious diet for the cure of obesity,
meaning thereby an expurgation of meat and an
indulgence in milk and farina. A great mis-
take was also made in supposing that the urine
was the outlet for fatty matters, while they
ignored the outlet by the lungs.

12

178 POLYSAROIA AND ITS TEEATMENT.

On a review of the foregoing case, it is worthy
of notice that the young woman has never men-
struated, and this, together with the absence of
sexual instinct, suggests the idea that the
ovaries are undeveloped, and that she may be
in the condition of a pig which has been spayed
for the purpose of fattening. Her voracious
appetite, and a diet in which farinaceous matters
largely entered, were doubtless factors in the
production of the result. When the diet, how-
ever, was restricted to the amount on which
her companions were only fairly nourished, still
she made fat in excess, to the amount of one
ounce and two fifths per week.

The exhibition of iodide of potassium failed
to be of value, other than preventing a continu-
ation of the morbid increase, while liquor
potassse, by interfering with digestion and
undermining her general health, produced slight
positive diminution. The results obtained from
the fucus vesiculosus were such as to justify its
being regarded as a safe and, to a certain extent,
effectual plan for diminishing obesity. It falls,
however, far behind what it is possible to effect
by a purely animal diet, and while to many the
latter remedy may appear as bad as the disease.

POLYSAECIA AND ITS TKEATMENT. 179

it should be remembered that a diet so purely
animal need not be insisted upon, a com-
promise may be made, keeping in view the
typical diet which should be approached as
nearly as possible in the treatment of these
cases.

It has been shown by Ranke that even when
large quantities of meat are taken, a decrease
in the weight of the body takes place, but that
the quantity of meat theoretically requisite to
maintain the system produces dyspepsia. In
the treatment of polysarcia, this difficulty is
avoided^ the quantity of meat is regulated to
supply the want induced by the tissue-changes
of the body, trusting to the superabundant
fatty matters of the system to supply the
demand of the respiratory process. In the case
I have detailed, the patient has continued the
meat diet for nine months without any dys-
pepsia, with improved tone, with a power of
resisting such a disease as scarlet fever, making
a speedy convalescence therefrom, and with
the positive advantages of diminished size and
increased enjoyment of life.

April 7th. — The patient has continued on a
diet of 15 oz. of meat daily, and her present

180 POLYS AECIA AND ITS TREATMENT.

weight is 133 lbs., indicating a continued
diminution at the rate of one pound two ounces
and a half a week. Her total loss in weight
has been 11 lbs. ; her decrease during the last
year, 70 lbs.

AN ACCOUNT OF A SECOND CASE

IN WHICH THE

CORPUS CALL08UM WAS DEFECTIVE,

' Trans, of Roy. Med. & Chir. Soc.,' 1866.

In the forty-fourth volume of the ' Trans-
actions ' of this Society I furnished the details
of a case in which there was a marked defect
in the great commissural connections of the
brain, associated with grave defect of the intel-
lectual faculties. I, at the same time, com-
pared the case under review with all others of
a similar nature which I could find recorded.

Another instance having come under my
notice which illustrates, in a characteristic
way, this rare abnormality, I am desirous of
placing it on record in the ' Transactions ' of
the same Society, which already contains
descriptions of the best marked examples.

A. B. came under my observation in the

182 DEFECTIVE CORPUS CALLOSUM.

autumn of 1858. He was the son of a clergy-
man, and had been submitted to tlie ordinary
process of education with but trifling results.
He had been taught to write a little, but he
never exercised the art. He had learned to
read easy words, and could answer simple
questions. His power of calculation was almost
nil. He was fond of music, had slight power
of imitation, and his memory, although defec-
tive, was good in relation to persons and
things. He was five feet four and three quarter
inches in height, and weighed ten stone one
pound. His trunk was well formed, and his
facial expression that of an imbecile. He was
shy, undemonstrative, fond of children (some
of whom he petted), while towards persons of
his own age and to the opposite sex he was
violent and passionate. His friends were very
desirous of asserting the non-congenital nature
of the mental condition, and attributed it to
masturbation. The diagnosis formed, however,
was that it was congenital, and that the mas-
turbation was an accidental circumstance.
This diagnosis was strengthened by reference
to the other members of the family, who,
although occupying good positions in the

DEFECTIVE COEPUS CALLOSUM. 183

world, were manifestly not of average intellec-
tual power. The habit of masturbation became
entirely broken, and he gave himself up to
simple employments, such as wheeling invalids
in a Bath chair, and otherwise aiding those
whom he petted.

He lived to forty years of age, when he died
from pleuro-pneumonia. An autopsy was made
thirty hours after death. The circumference
of the head was 21 j in.; the bilateral curve
11^ in. ; the antero-posterior curve 12 in. ;
the bilateral diameter b-^o in. ; the antero-pos-
terior diameter 6-j^ in. The calvarium was
unsymmetrical and dense, shelving anteriorly;
the posterior clinoid processes were converted
into sharp needle-like points ; the encephalon
weighed 2 lb. 14 oz. On separating the two
hemispheres the almost entire absence of the
corpus callosum was apparent, and the velum
interpositum exposed to view. A small carti-
laginous-like band, -^\ in. in breadth and 2-4- in.
in thickness, situated opposite the corpora
striata, was the only representative of the great
commissure. The fornix was represented by
two thin posterior pillars ; the body of the
fornix and its anterior pillars were absent.

184 DEFECTIVE CORPUS OALLOSUM.

The right optic thalamus was very much larger
than the left. The cineritious portion of the
brain was pale, the posterior cornua of the
lateral ventricles were distended with straw-
coloured serum, and the Pineal gland was the
size of a wild cherry. The middle commissure
was absent. The rarity of this abnormality
may be indicated by the circumstance that it is
only the second time I have met with it in the
dissection of 150 brains of idiots.

MARRIAGES OF CONSANGUINITY

IN EELATION TO

DEGENERATION OF RACE,

' London Hospital Eeports,' 1866.

Peobably no subject which has engaged the
attention of the medical statist has given rise to
more widely divergent views, certainly no in-
quiry on the part of the physiologist, has been
productive of less practical results, than the
one which heads this paper. There is a class,
and probably a large one, which looks upon
consanguineous unions as universally productive
of evil, and where the worst consequences are
not met with, regard them as mere exceptions
to an all but universal rule. To some extent
this opinion has permeated society, and although
it has failed in preventing such unions, the
popular view has of late years been tending to

186 ON THE EESULT OF

a conviction that degeneracy of race is to be
largely attributed to the union of blood-relations.
Thus Duvay, of Lyons, asserts " that in pure
consanguinity, isolated from all circumstances
of hereditary disease, resides, ipso facto, a prin-
ciple of organic vitiation."

On the other hand, a not inconsiderable
section regard this conclusion with doubt, and
teach that consanguineous unions may be
effected with impunity. We may place, as re-
presenting this party, and in antithetical rela-
tion to that of Duvay, the assertion of Dr.
Gilbert Child, that " the marriages of blood-
relations have no tendency, per se, to produce
degeneration of race."

The arguments of the former are drawn from
examples of a somewhat isolated character, and,
in the language of their opponents, "attempt
often to prove too much." No one, I think,
with a previously unbiassed mind, can read the
numerous examples which are cited to prove as
the result of such unions sterility, deaf-mutism,
idiocy, and other characteristics of degeneration,
without coming to the conclusion that the cases
from which they argue are selected ones, and
that the cause they advocate is damaged by

MAEEIAGES OF CONSANGUINITY. 187

special pleading wliere there should have been
judicial deliberation. Writing from a stand-
point of observation which enables me to give
an opinion on the subject, and having regard
to a great deal that has been written, I cannot
but join Dr. Child in his very just remark, " to
say that all but half the children of the mar-
riages of cousins are idiotic, is simply to say
the cases from which the statistics were drawn
are not fair cases."

The arguments of the party, of which I have
placed Dr. Child as the exponent, are mainly
based on observations on the results of the
modern system of breeding among the lower
animals, and on the examples furnished by the
Hebrew race and the North American Indians.
The racial degeneracy, which it is the pur-
pose of this paper to examine in its relation to
consanguineous unions, is that congenital men-
tal defect, which, manifesting itself in different
varieties as to intensity, has received the name
of idiocy. •

My notes refer to 1138 cases of idiots, 763
being males, and 385 females, which I may say
en passant is about the ratio, according to my
experience, in which the sexes are affected by

188 ON THE EESULTS OF

idiocy, viz. in the proportion of about two to
one.

I have taken the records with every care as
to accuracy, and from the number have excluded
all cases in which there was impossibility in
obtaining information or elements of doubt
when obtained. Influenced only by these cir-
cumstances, I have eliminated 196 males and
90 females, leaving 557 males and 295 females,
or a total of 852, on which the arguments will
be based.

Of the 753 male idiots, 33 were the progeny
of first cousins ; in two of these instances there
was another element elicited, viz. in one case
the mother was also the product of first cousins,
and in the other the mother was the product of
cousins germain, involving, therefore, in these
two cases, an increased intensity of blood-
relationship. Three cases were the progeny of
second cousins. Four of third cousins. In all,
40 cases out of 753, or only rather more than
5 per cent., could by any possibility have been
due to consanguineous unions. Of the 295
females, 13 were the progeny of first cousins,
3 were the children of second, and 4 those of
third cousins. In all, 20 among 295, or little

M.4.RRIAaES OF CONSANGUINITY. 189

less than 7 per cent., could have been caused by
the marriage of blood-relations.

The difference in the percentage of idiots, the
progeny of cousins, between the male and female
sex is remarkable, but may, I think, be explained
by the existence of a preponderating cause of
idiocy on the part of males over females, in the
larger size of the male cranium at birth, and
the consequent greater risk. of injury to the
cranial contents during parturition.

I am unable to say with certainty how fre-
quently the marriage of blood-relations takes
place in an ordinary community, but I have
made a careful inquiry into the family history
of 200 persons, collected from different dis-
tricts, who are sane and healthy, and who belong
to different families, and I find only one is
the offspring of cousins ; being half per cent.,
and I learn that in that one instance he is the
son of unusually healthy parents. Certainly,
in his case, there is no symptom of either phy-
sical or mental degeneracy, and he would pro-
bably be selected from among the 200 as one
of the most robust and vigorous.

I propose now, further, to inquire into the
cases of idiocy from which my statistics are

190 ON THE EESULTS OF

drawn, and endeavour to discover if there are
any other factors, besides that of consanguinity,
to account for the manifestation. For this
purpose I quote from the notes of 20 cases
taken, without selection, from my portfolio, and
which may, therefore, be fairly regarded as
typical of the whole.

Case 1. — J. Y. T., male, born in London,
father and mother healthy and of sound mind,
but first cousins. The father's mother had
hemiplegia at 73. Mother was frightened when
six weeks advanced in pregnancy by seeing her
mother with paralysis, and to this she attributes
the idiocy of the son, who is a microcephale.
Three sisters, all healthy. J. Y. T. is the fourth,
and last born.

Case 2. — M. M. Y., female, born at Calne,
father and mother first cousins. The mother's
parents were also distantly related. The father
healthy and of sound mind, but his brothers
and sisters with consumptive tendencies. The
mother died from tumour of the brain, several
of her relatives died from consumption. M.
M. Y. is the second-born and a twin, the other

MARRIAGES OP CONSANGUINITY. 191

twin healthy and of sound mind. This child
was remarkably small when born, is deaf, and
had fits for many years. She has one cousin
who is demented from epilepsy.

Case 3.— A. E. Y. S.,male, born at Walworth.
The father and mother were first cousins. The
father was dehcate, sound in mind, but intem-
perate, his relations healthy. The mother
healthy and of sound mind, had given birth to
twins twice, her family generally consumptive.
A. E. Y. S. io the eighth-born, and one of his
brothers died from consumption. The mother
was frightened by a cat during the seventh
month of her pregnancy, and was ill a week in
consequence. She attributes the idiocy to her
husband's habitual intemperance.

Case 4. — M. A. S., female, born in London.
Father and mother first cousins. Father of
sound mind, died from pulmonary hemorrhage.
One of his sisters died from consumption.
Mother consumptive, has also lost one sister
from consumption. M. A. S. is the fifth-bor-n,
and had four brothers and one sister, all have
died from consumption.

192 ON THE RESULTS OP

Case 5. — F. H., female, born in Lancashire.
Father and mother were second cousins. The
father healthy and of sound mind ; his father
lost his sight when a young man (amaurosis ?),
two brothers died from consumption. Mother
healthy and of sound mind, her aunt on father's
side insane. The mother married twice, the
first time to a person not I'elated, and had three
children, two girls healthy, and one boy who
has epileptic fits. She afterwards married her
second cousin and had two girls, who are
healthy, then a boy, who is decidedly idiotic,
and then F. H., who has little or no mental
power. F. H. is the seventh-born. Mother
states thai? she believes the cause of the idiocy
of the first idiot child was from fright, and
that of the second from thinking of the idiocy
of the former.

Case 6. — C. E. H., female, born in Leicester-
shire. Father and mother first cousins. Father
is a clerk in holy orders, healthy now, but was
very delicate when at college ; his uncle was
imbecile, his father was eccentric, and acquired
drinking habits, his aunt died from phthisis.
The mother is very deaf, her sister died from

MAERIAGES OF CONSANGUINITY. 193

cancer. C. E. H. has three brothers and two
sisters of average physical and mental power.
She was the first-born, and during the preg-
nancy the mother had great anxiety about
pecuniary matters. The forceps were em-
ployed at parturition, and the head was greatly
crushed.

Case 7. — J. C, female, born in Surrey.
Father and mother second cousins. Father had
fits when a child, is very ailing, and feeble in
mind. No family history. The mother not
very strong, lost a brother from consumption.
J. C. is the sixth-born ; her eldest brother died
from acute hydrocephalus; the rest are all bright
although not very strong. The mother says
she saw, when seven months advanced in preg-
nancy, a girl precisely like her daughter both
mentally and physically.

Case 8. — J. T. B., male, born at Wingham.
Father and mother third cousins ; father healthy
and of sound mind, very deaf; his cousin became
blind from study. Mother healthy, but all her
relations consumptive. J. T. B. is the seventh-
born, and is a twin-child; his twin-sister is

13

194 ON THE RESULTS OF

very intelligent, as are also another sister and
eight brothers.

Case 9. — E. P. 0., male, born at Tiverton.
Father and mother first cousins ; father died
from Bright' s disease after five years' illness;
relations healthy. Mother healthy, but ner-
vous ; had bad health during her pregnancy,
and was much distressed by her eldest child
having croup in Paris, and not being able to
procure a doctor. She had a very bad labour,
owing to the large size of the child. There
are two brothers and three sisters, all particu-
larly intelligent. E. P. C. is the fourth-born.

Case 10. — W. G., male, born at Dorking.
Father and mother were second cousins. Father
healthy, and of sound mind; has lost five
brothers and sisters from consumption, and
has one sister insane. The mother has had a
fistula, is of sound mind. She was very low-
spirited during pregnancy at the prospect of
another child, with limited means for the support
of the family. W. Gr. is the fourth-born, and
has had three brothers and two sisters ; one
brother died from scarlatina, one is rather deli-
cate, the rest are healthy and intelligent.

MAEEIAGES OF OONSANGUIJSIITY. ]95

Case 11. — W, A. P., male, born at Peckham.
Father and mother first cousins. The father
was healthy, but below the average in mental
power ; his relations were healthy. The mother
has always been delicate, and is very nervous,
had an aunt insane, all her brothers and sisters
died young. W. A. P. is the eleventh-born,
and has had four brothers and six sisters. The
first-born, a male, is an idiot, one brother died
of inflammation of the lungs, one of convulsions
at a fortnight old. Four sisters are dead — two
were twins, one died at birth, and the other
twin-child, when ten days old, of fits, one died
from fever; there are two sisters and one
brother living, who are all intelligent.

Case 12. — W. R., male, born in London.
Father and mother were first cousins. Father
has good health, but is very irritable and de-
sponding ; his mother died of consumption, and
he lost one sister from congestion of the brain.
Mother healthy, has lost one sister from cou-
sumption, and has an uncle imbecile. The
mother sufl^ered severely from sea-sickness
when in the fourth month of pregnancy. The
umbilical cord was obliged to be divided before

196 ON THE RESULTS OF

the birth, animation was suspended and had to
be resuscitated by artificial means. W. R. is
the eleventh-born, has had eleven brothers and
sisters, all of whom had average mental and
bodily power.

Case 13. — R. S., male, born in London.
Father and mother first cousins. The father
healthy, sober, and steady, family healthy.
The mother suffers from chronic bronchitis,
sound in mind, and family healthy. The rela-
tive ages of father and mother at the birth of
R. S. were 41 and 29. The labour was linger-
ing, and ergot of rye given twice ; the head was
misshapen, and the child made a strange noise
when born, R. S. is the fourth-born, and has
had one brother and seven sisters. One had
no bone on one side of the head, and lived only
two days ; four died at birth, but seemed all
right. The rest quite healthy children. The
first three born are the healthy ones, the rest
have all been defective or have died. The
mother miscarried with a child with one leg.

Case 14. — J, B., male, born at Tottenham.
The father and mother were first cousins. The

MARRIAGES OF CONSANGUINITY, 197

father has good health, but is of low intelli-
gence: his relations healthy. The mother is
delicate, and lost a brother and sister from con-
sumption. J. B. was the third-born, and had
one brother and four sisters ; one boy had fits
and died from consumption, one girl died from
epilepsy at seven years, the rest healthy and
bright.

Case 15.— E. P., male, born at Bath. The
father and mother are second cousins. The
father has average health, but is a drunkard,
six of his immediate relatives stammer. The
mother has very poor health, and suffers from
uterine disease ; two of her sisters died young
from consumption. The mother was ill during
the whole of her pregnancy, fell downstairs
during the seventh month, was nervous, and
was disturbed by hallucinations. E. P. was
the second-born, and had three brothers and
three sisters ; one died of water on the brain,
one of scarlet fever, and one of consumption.
Three are idiots.

Case 1G. — J. A. V., male, born in London.
Father and mother are first cousins. Father is

198 ON THE RESULTS OF

healthy, but his father was eight months in an
asylum with mania, and recovered ; father's
mother very eccentric ; his sister had spinal
disease, and died from consumption. Mother
healthy, but nearly all her immediate relatives
consumptive. She had much trouble and busi-
ness difficulties during her pregnancy. J. A. V.
is the fourth-born, had two brothers and one
sister who were intelligent.

Case 17. — J. T. W., male, born in London.
Father and mother are first cousins. Father is
a very weak and nervous man, faints frequently,
and his whole bearing is like one suffering from
mercurial tremor. The mother has good health,
but is very nervous, her mother is also nervous,
and bordering on being insane, one uncle died
insane, and one cousin is imbecile. She fell
downstairs when six months pregnant, and about
the same time she was much frightened by her
husband falling down in a fainting fit, which
induced in her uterine action and a considerable
amount of flooding. J. T. W. is the first-born,
and has had five brothers ; one died from a fit
during an attack of whooping-cough, one died
from bronchitis, one is paralysed on one side,

MARRIAGES OF CONSANGUINITY. 199

and another is three years and a half old, and
cannot talk, is only just able to walk, and has
a large head.

Case 18. — B. H. H., male, born at Lewes.
Father and mother were first cousins. Father
is healthy, but irritable ; one of his sisters died
from consumption, and another, who also died
from consumption, was subject to delusions.
The mother died from consumption, and had
an uncle who suffered from dementia, thought
to have been induced by drink. She was
frightened two months before her confinement
by stepping on an adder. The labour was lin-
gering, and the child's head much distorted.
E. H. H. was the first-born, and was born with
animation suspended; he had one sister only,
who was prematurely born, and who died three
days after her birth.

Case 19. — Gr. K., male, born at Woolwich.
Father and mother were first cousins. Father
is healthy, and of sound mind ; his relatives
were of average health and mental power.
Mother healthy, and of sound mind ; her mother
was insane ; her aunt died in an asylum ; and

200 ON THE EESULTS OP

another aunt's child suffers after every confine-
ment from puerperal mania. G-. K. was the
second-born, and had one brother and three
sisters ; one sister is an idiot, and another was
quite helpless, and died at the age of fourteen
months.

Case 20.— T. E., male, born at Thetford,
Norfolk. Father and mother were first cousins.
Father died from a contraction of the bowel,
sound in mind, and steady ; his mother used to
stammer ; mother very nervous ; she was
frightened during her pregnancy by seeing an
idiotic man. Labour lasted twenty-eight hours,
and she was delivered with instruments. T. R.
is the first-born, and had three brothers and one
sister ; one brother died from whooping-cough ;
the second and third were twins, and are very
healthy ; all sound in mind.

My own statistics differ so much from those
published by Dr. Howe, of the United States,
and on which many arguments have been based,
that I am induced to place them in contrast : —

Dr. Howe's 17 marriages produced 95 chil-
dren— i. e. 5*58 each. Of the 95 children —

MARRIAGES OP CONSANGUINITY. 201

37 were of tolerable health.

1 was a dwarf.

1 was deaf.
12 were scrofulous or puny.
44 were idiots.

Total 95

Thus more than 46 per cent, were idiots.
' The 20 marriages, relating to my own cases,
produced 138 children — i. e. 6*9 each. Of the
138 children —

75 had average health and intellect.
11 were consumptive.

8 were still-born.
4 died from convulsions or fits.

2 were hydrocephalic.

7 died young from infantile complaints.

6 were puny and delicate.
25 were idiots.

Total 138

It will be seen that only a little more than
18 per cent, were idiots.

It will be interesting to place also in contrast
the results of 20 marriages, in which there was

202 ox THE RESULTS OF

no consaDguinity, but in which there were one
or more instances of mental defect in the pro-
geny of each family, and which have been taken,
like the former twenty cases, from a much
larger number, without any principle of selec-
tion. The 20 non-sanguineous marriages
produced 145 children, or 7'25 each. Of the
145 children —

83 had average health.

1 was consumptive.
11 were still-born.

3 died from convulsions or fits.

2 were hydrocephalic.

13 died from infantile complaints-

6 were puny, or dwarfed.
26 were idiots.

Total 145

It will be seen that 18 per cent, were idiots.
In the case of the consanguineous progeny,
55 per cent, were of average health ; in the non-
consanguineous, 57 per cent. No one, I think,
who has had an opportunity of investigating
the subject, or who compares these statistics
with Dr. Howe's, can avoid coming to the con-
clusion that Dr. Howe's 17 cases were not

MARRIAGES OP CONSANGUINITY. 203

typical of what is to be met with in this country.
Only 39 per cent, of the progeny in his cases
had average health.

I have shown that about 6 per cent, of those
suffering from congenital mental defect are
the product of consanguineous marriages,
wliile, among the healthy and vigorous, only
about half per cent, may be placed as the result
of such unions. One cannot, therefore, resist
the conviction that the union of blood-relations
has some influence in the deterioration of our
species. What that influence is, however, can
only be determined by a further investigation
into the etiology of the 20 cases I have cited.

Out of the 20 cases, among whom the aver-
age number of children were 6'9 each, no less
than 5, or 25 per cent., were primiparge. This
of itself, according to my observation, is some-
times a cause of idiocy. It may be explained,
I believe, by the greater injury sustained in the
birth than at subsequent labours, and is analo-
gous to the determining cause of the pre-
ponderance of male over female idiots before
alluded to.* No less important is the fact,

* In the statistics of th(3 maternity department of the
London Hospital (' London Hospital Reports,' vol. i,

204 ON THE RESULTS OF

that in two cases the forceps were employed at
the birth of the child, or in 10 per cent, of the
cases. I find from the statistical report of the
maternity department of the London Hospital,
by Mr. Heckford, published in the first volume
of the ' London Hospital Eeports,' that the
forceps were employed only in 8 per cent, of
the children alive. It would not be difficult to
prove, by reference to all the notes I possess,
that instrumental interference is of itself a cause
of idiocy. In two of the 20 cases, in which in-
struments were not employed, the head of the
child was much missphapen by the difficulty of
the labour.

One was a twin-child, and there is reason to
believe that this condition may, of itself, be
conducive to defective mental development.
Suspended animation was reported in two cases,
or 10 per cent. ; how far this may influence the
future development of the child, I shall inquire
into, in a future paper.

Ergot of rye was given in one case ; but I
am not aware of any observations on the use
of this drug as a cause of idiocy.

p. 254), it is stated that the stillborn males exceeded the
females by 35 per cent.

MARRIAGES OP CONSANGUINITY. 205

This disposes of all the possible causes in-
fluencing the child at parturition. I have now
to inquire into the hereditary influences which
might have affected the ovum, and I think it
will be readily granted that no breeder of cattle,
apart from all question of breeding in and in,
would select analogous stock for propagation
from, to those which constitute the parents of
the twenty cases I have quoted.

Thus, among the progenitors of the twenty,
in no fewer than twelve instances, was phthisis
abundantly established in the family history of
one or both parents.

In 12 cases there was well-established
history of insanity, epilepsy, or imbecility in
the family of one or both progenitors reaching
to the large amount of 60 per cent. In 2
cases the fathers were habitual drunkards. In
one instance the mother was very deaf, and the
same case furnished the solitary example of
cancer.

There were only 4 cases in which there
did not exist either a history of insanity or
phthisis in the family. In the first of these the
father's mother stammered when young, the
mother stated that she was nervous during her

206 ON THE RESULTS OF

pregnancy, during whicli she was frightened
by an idiotic man. Tlie boy had four brothers
and sisters, all of whom were healthy, and he
was one of the cases delivered by forceps. In
the second case there was no history of here-
ditary taint. There was, however, disparity in
the ages of the parents : father was 41 and the
mother 29. The labour was very lingering,
and it was the one case in which ergot of rye
was administered.*

In the third case, the father was suffering
from Bright's disease at the time of procreation,
from which disease he died.

The fourth case is the only one in which the
consanguinity stands as an isolated cause, and
even in this instance there are three sisters
perfectly sound, and it is the only example of
degeneracy in the family, while the mother
asserts that she was frightened by seeing her
mother with paralysis at the age of 73. It is
worthy of remark that the father's mother also
died from paralysis at the age of 70. The boy
is a microcephale and the last-born ; the father,
about the time of the procreation, grew thrift-

* Dr. Eamsbotham lias shown that the ergot of rye
influences unfavorably the viability of the child.

MARRIAGES OP CONSANGUINITY. 207

less, ran away to Australia, and has not been
heard of.

It is also noteworthy that these four excep-
tional examples are all males. Reviewing the
whole of these cases, there is only one, and that
the one just mentioned, in which there is not
quite sufficient to account for the idiocy apart
from consanguineous influences.

Since writing the foregoing, my attention
has been called to a paper of Dr. Mitchell's,
read before the Medico -Chirurgical Society of
Edinburgh,* in which, making observations
from a similar point of view to myself, on a
different field, he has arrived at very opposite
conclusions. He found in Scotland that more
than every sixth idiot born in wedlock was the
child of cousins. I am unable to account for
such a wide disparity, and in the face of it can
only reiterate the care with which my informa-
tion has been collected, and the impartiality
with which my results are here presented. My
own researches conclusively show that in Eng-
land, at least, every fourteenth idiot only is the
child of cousins. But can it be as certainly

* ' Edin. Med Journ.,' vol viii, p. 872.

208 ON THE RESULTS OF

shown that the relationship per se is the cause
of the idiocy? I think not, and the analysis I
have made clearly shows that in the vast majo-
rity of such, so great in fact that it may almost
be said to be universal, other causes were
operating which were merely intensified by the
relationship. Had the same care been exercised
in the selection of relations as is displayed by
the breeder of race-horses, vastly different
results might have ensued ; or were the prac-
tice of the coloured races of North America in
force, of destroying all the weak, rachitic, and
diseased children, the intermarriage of cousins
would not have displayed the facts which I
have furnished. Consanguinity has doubtless
the power of aggravating any morbid tendency,
as I believe it has of perfecting any good
quality. Any statistics on the results of the
marriage of relations are of doubtful value
unless they give the life-history of the progeni-
tors. What a different aspect the whole matter
assumes when this plan is adopted, will be
apparent to the readers of this paper. When-
ever a similar investigation is made, I believe it
will be found, as in the subjects of my own
inquiry, that consanguinity is only one of the

MAREIAGBS OF CONSANGUINITY. 209

factors, and not the most important one, in the
production of deterioration.

If our advice is sought, it will be our duty
to inquire into other elements which are less on
the surface, but which have equal or even greater
potentiality for evil.

iiUiances, such as I have exhibited, with
hereditary disease on both sides, should be dis-
countenanced even where there is no element
of consanguinity. It would only be a part of
a true philosophy to render more forcible our
opposition where blood-relationship would have
a well-determined tendency to aggravate the
wrong.

14

21 0 OJBSEKVATIONS ON AN ETHNIC

OBSERVATIONS

ETHNIC CLASSIFICATION OF IDIOTS.

• London Hospital Reports,' 1866.

Those who have given any attention to con-
genital mental lesions must have been fre-
quently puzzled how to arrange, in any satis-
factory way, the different classes of this defect
which have come under their observation.
Nor will the difficulty be lessened by an appeal
to what has been written on the subject. The
systems of classification are generally so vague
and artificial that not only do they assist but
feebly in any mental arrangement of the pheno-
mena which are presented, but they completely
fail in exerting any practical influence on the
subject.

CLASSIFICATION OP IDIOTS. 211

The medical practitioner who may be con-
sulted in any given case, has, perhaps in a very
early condition of the child's life, to give an
opinion on points of vital importance as to the
present condition and probable future of the
little one. Moreover, he may be pressed as to
the question, whether the supposed defect dates
from any cause subsequent to the birth or not.
Has the nurse dosed the child with opium?
Has the little one met with any accident ? Has
the instrumental interference which maternal
safety demanded been the cause of what seems
to the anxious parents a vacant future ? Can it
be that when away from the family attendant
medicine has been injudiciously prescribed?
Can, in fact, the strange anomalies which the
child presents be attributed to the numerous
causes which maternal solicitude conjures
to the imagination, in order to account for a
condition, for which any cause is sought rather
than hereditary taint or parental influence ?
Will the systems of classification, either all to-
gether, or any one of them, assist the medical
adviser in the opinion he is to present, or the
suggestions which he is to tender to the anxious
parent? I think that they will entirely fail

212 OBSERVATIONS ON AN ETHNIC

liim in the matter, and that he will have in
many cases to make a guarded diagnosis and
prognosis, so guarded, in fact as to be almost
valueless ; or to venture an authoritative asser-
tion which the future may or may not confirm,

I have for some time had my attention
directed to the possibility of making a classifi-
cation of the feeble-minded, by arranging them
around various ethnic standards, — in other
words, framing a natural system to supplement
the information to be derived by an inquiry
into the history of the case.

I have been able to find among the large
number of idiots and imbeciles which come
under my observation, both at Earlswood and
the out-patient department of the hospital,
that a considerable portion can be fairly referred
to one of the great divisions of the human
family other than the class from which they
have sprung. Of course there are numerous
representatives of the great Caucasian family.
Several well-marked examples of the Ethiopian
variety have come under my notice, presenting
the characteristic malar bones, the prominent
eyes, the pufi'y lips, and retreating chin. The
woolly hair has also been present, although not

CLASSIFICATION OF IDIOTS. 213

always black, nor has tlie skin acquired pig-
mentary deposit. They have been specimens
of white negroes, although of European
descent.

Some arrange themselves around the Malay
variety, and present in their soft, black, curly
hair, their prominent upper jaws and capacious
mouths, types of the family which people the
South Sea Islands.

Nor have there been wanting the analogues
of the people who, with shortened foreheads,
prominent cheeks, deep-set eyes, and slightly
apish nose, originally inhabited the American
Continent.

The great Mongolian family has numerous
representatives, and it is to this division I wish,
in this paper, to call special attention. A very
large number of congenital idiots are typical
Mongols. So marked is this that, when placed
side by side, it is difficult to believe that the
specimens compared are not children of the
same parents. The number of idiots who
arrange themselves around the Mongolian type
is so great, and they present such a close
resemblance to one another in mental power,
that I shall describe an idiot member of tbis

214 OBSERVATIONS ON AN ETHNIC

racial division, selected from the large number
that liave fallen under my observation.

The hair is not black, as in the real Mongol,
but of a brownish colour, straight and scanty.
The face is flat and broad, and destitute of pro-
minence. The cheeks are roundish, and ex-
tended laterally. The eyes are obliquely placed,
and the internal canthi more than normally dis-
tant from one another. The palpebral fissure
is very narrow. The forehead is wrinkled
transversely from the constant assistance which
the levatores palpebrarum derive from the
occipito-frontalis muscle in the opening of the
eyes. The lips are large and thick with trans-
verse fissures. The tongue is long, thick, and
much roughened. The nose is small. The
skin has a slight dirty yellowish tinge, and is
deficient in elasticity, giving the appearance of
being too large for the body.

The boy's aspect is such that it is difficult to
realise that he is the child of Europeans, but so
frequently are these characters presented that
there can be no doubt that these ethnic features
are the result of degeneration.

The Mongolian type of idiocy occurs in more
than 10 per cent, of the cases which are pre-

CLASSIFICATION OF IDIOTS. 215

sented to me. They are always congenital
idiots, and never result from accidents after
uterine life. They are, for the most part, in-
stances of degeneracy arising from tuberculosis
in the parents. They are cases which very
much repay judicious treatment. They require
highly azotised food with a considerable amount
of oleaginous material. They have considerable
power of imitation, even bordering on being
mimics. They are humorous, and a lively
sense of the ridiculous often colours their mimi-
cry. This faculty of imitation may be culti-
vated to a very great extent, and a practical
direction given to the results obtained. They
are usually able to speak ; the speech is thick
and indistinct, but may be improved very greatly
by a well-directed scheme of tongue gymnastics.
The co-ordinating faculty is abnormal, but not
so defective that it cannot be greatly strength-
ened. By systematic training, considerable
manipulative power may be obtained.

The circulation is feeble, and however much
advance is made intellectually in the summer,
some amount of retrogression may be expected
in the winter. Their mental and physical capa-
bilities arc, in fact, directly as the temperature.

216 OBSERVATIONS ON AN ETHNIC

The improvement whicli training effects in
them is greatly in excess of what would be pre-
dicated if one did not know the characteristics
of the type. The hfe expectancy, however, is
far below the average, and the tendency is to
the tuberculosis which I believe to be the here-
ditary origin of the degeneracy.

Apart from the practical bearing of this
attempt at an ethnic classification, considerable
philosophical interest attaches to it. The ten-
dency in the present day is to reject the opinion
that the various races are merely varieties of
the human family having a common origin, and
to insist that climatic, or other influences, are
insufficient to account for the different types of
man. Here, however, we have examples of re-
trogression, or, at all events, of departure from
one type and the assumption of the characteris-
tics of another. If these great racial divisions
are fixed and definite, how comes it that disease
is able to break down the barrier, and to simu-
late so closely the features of the members of
another division ? I cannot but think that the
observations which I have recorded are indica-
tions that the differences in the races are not
specific but variable.

CLASSIFICATION OF IDIOTS. 217

These examples of the result of degeneracy
among mankind, appear to me to furnish some
arguments in favour of the unity of the human
species.

218 ON IDIOCY AND ITS

ON IDIOCY AND ITS RELATION TO
TUBEECULOSIS.

' The Lancet,' vol. ii, 1867.

The causes which have been assigned as
productive of idiocy are numerous, and some
have received special advocacy. Thus we are
asked to believe that one of the most profound
misfortunes which aflSicts our race — which to
a great extent blots out the characteristics of
man, and approximates him to the lower animals
— arises from sucking the thumb ; and that if
we could prevent a " fruitless sucking " idiocy
would be immensely diminished, even if it did
not cease to exist. Others, with more show of
reason, urge the intermarriage of blood rela-
tions as the prevailing cause ; and so far does
a belief in the potency of this latter element
permeate society that I have been often gravely

EBLATION TO TUBERCULOSIS. 219

asked whether intermarriage of relations is not
the cause of the idiocy of three fourths of the
cases which come under my observation. 'No
one who has had an opportunity of investiga-
ting the influences which are at work in the
production of congenital mental diseases can
fail to be struck with the fact that they are,
for the most part, to be traced to some inherent
vice of constitution in the progenitors. He will
discover in the parents elements of degeneracy
which must have had their share in producing
the catastrophe. He will notice how by degrees
the stock has deteriorated. He will be able to
estimate how intemperance or sensuality leads
slowly but surely to idiocy — how physical weak-
ness of the parents culminates in the mental
blight of the child.

Amongst the influences which have been
regarded as connected with idiocy, very little
attention has been given to that of tuberculosis,
and I am not aware that any observations have
been made with reference to the connection of
these two maladies.

Several writers have discussed the relations
between insanity and tuberculosis, and have, I
think, made it tolerably evident that there is

220 ON IDIOCY AND ITS

more than an accidental connexion between
them.

At the Earlswood Asylum, where the follow-
ing observations have been made, the subjects
of the inquiry are not likely to present an unfair
proportion of tubercular idiots. Rather would
they be likely to be below the average. The
inmates are, for the most part, elected after
great exertion, and the friends of a phthisical
idiot would scarcely be likely to undertake the
trouble for a manifestly short-lived child, even
if the rules of the institution did not exclude it.

During the past eight years, from 1859 to
1866 inclusive, there have been 201 deaths.
During this time there have been two epidemics
of measles, one of scarlet fever, and two of
whooping-cough, which have all added to the
mortality. Moreover, a large proportion of
the patients who succumbed to these epidemic
diseases were those who would in all probability
have eventually died of phthisis but for their
intervention. Notwithstanding this circum-
stance there remains the fact, which my notes
record, that, of the whole mortality, 39*8 is due
to phthisis. To appreciate fully the meaning
of these figures, it is necessary to consider the

RELATION TO TUBERCULOSIS.

221

rate of mortality wliich rules amongst an idiot
population. My notes show that, taking the
last eight years, in some of which there were
epidemics, while others were entirely free
therefrom, the mortality presented an average
of about 73 "3 per 1000 ; whereas the mortality
of the district in which the asylum is situated
was about 18 per 1000.

Average

Gross

Deaths

Date.

popula-

mor-

from

—

1859

tion.

tality.

phthisis.

2851

13

7

1860

3081

22

7

Epidemic of typhoid.

1861

318i

23

13

1862

322

33

8

Epidemic of measles.

1863

sm

47

15

Epidemic of measles and
scarlatina.

1864

369f

19

10

1865

4121

13

9

1866

423i

31

11

Epidemic of measles.

The statistics of London show that the deaths
from phthisis constitute 115 per 1000 of the
general mortality. My notes of the causes of
death at Eiarlswood indicate that phthisis was
the actual cause of death in 398 per 1000 of
the general mortality. The significance, how-
ever, of this, as before observed, can only be

222 ON IDIOCY AND ITS

rightly estimated by recollecting that the general
mortality is four times that of an ordinary com-
munity.

It will be obvious that, in consequence of the
greater readiness with which idiots succumb to
epidemic or other diseases, the proportional
deaths from phthisis are therebymuch decreased.
This element may be fully brought out by
dividing the eight years ; bringing together the
four epidemic years, and comparing them with
the four non-epidemic years. It will then be
seen that during the epidemic years 1860, 1862,
1863, and 1866, the deaths from phthisis num-
bered 297 per 1000 of the general mortality, or
considerably more than twice the ratio which
rules in London ; while in the non-epidemic
years 1859, 1861, 1864, and 1865, the deaths
from phthisis reached the enormous proportion
of 570*58 per thousand of the general mor-
tality. I now propose to present a tabular
view of the age and sex of those who died from
phthisis.

Age.

Male.

Female.

Total,

7

1

0

1

8

1

0

1

9

1

2

3

10

3

0

3

EELATION TO TUBERCULOSIS.

223

11

12
13
14
15
16
17
18
19
20
21
23
27
20

Male.

Female.

2

1

3

1

6

2

5

2

1

0

4

1

2

6

4

3

8

1

7

1

6

2

2

0

1

0

1

0

Total.
8
4
8
7
1
5
8
7
9

58 22 80

Dividing the ages into quinquennial periods,
it will be observed that the greatest mortality
from phthisis was from fifteen to twenty years
of age.

From 5 to 10 years ... 8

„ 10 to 15 „ 23

„ 15 to 20 „ 38

„ 20 to 25 „ 10

„ 25 to 30 „ 2

The above details have reference solely to
ante-mortem diagnosis and have included cases
where the death was evidently caused by

224 ON IDIOCY AND ITS

phthisis. I have, however, made an analysis of
the last hundred of my post-mortem records,
and I find that no fewer than 62 per cent, were
subjects of tubercular deposit. There were 62
males, and tubercular deposit was found in 49
instances, or 79*03 per cent. There were 38
females, and of these 13, or 34 per cent., were
tubercular.

Dr. Clouston, in the ' Journal of Mental
Science' for 1863, has analysed the post-mortem
records of the insane at the Royal Edinburgh
Asylum, and found that 60*9 per cent, had
tubercular deposit. It would appear that idiots
are slightly more liable to tuberculosis than the
insane, but there is a remarkable difference
between the proclivity of the two sexes. While
among the insane, 51 '7 per cent, of the males
were tubercular, 73 per cent, of the females had
tubercular deposit. Among idiots, however,
while the females have a remarkable immunity,
the deposit being found in only 34 per cent.,
among the males no less than 79*03 per cent.,
or more than twice the ratio, had tubercle in
some of their organs.

If we inquire into the sex of those whose
death resulted from phthisis, and in whom the

EELATION TO TUBERCULOSIS.

225

diagnosis was made during life, we shall also find
that the females suffered in a less degree than
the males. While 31*9 per cent, of the female
mortality resulted from phthisis, this disease
was the cause of death in 44'6 per cent, of the
males.

The following table will give the distribution
of the deposit in the different organs : —

Total number of cases referred to, 100.

Males. Females.

Total number of cases

tubercular
Lungs

Lungs, much deposit
Lungs, slight deposit
Deposit in right lung
Deposit in left lung
Peritoneum
Nervous centres
Bronchial glands
Liver
Kidneys
Spleen

found

37 .

. 25

31 .

. 21

24 .

. 14

7 .

7

26 .

. 17

27 .

. 21

4 .

. 3

3 .

. 3

12 .

6

. 5 .

. 4

4 .

0

1

7 .
1 1 II

2

1 1

Total.

62
52
38
14
43
48

7

6
18

9

4

9

It is worthy of remark that tubercle is rarely
found in the encephalon. In only two cases
did this occur ; in one the corpus striatum was
the seat of the deposit, and in the other the

15

226 ON IDIOCY AND ITS

cerebellum. The most noticeable character
observed was the extreme pallor of the cortical
substance of the encephalon ; and so frequent
was this that it was all but universal. Occa-
sional softening of the fornix and the neigh-
bouring parts was met with, but not nearly so
frequently as paleness of what should be the
grey portion of the brain.

In several of the cases included in the above
record, most careful inquiry failed to discover
any family history of tuberculosis; and the
brothers and sisters were thoroughly vigorous.
In these cases the tuberculosis appears to have
been the sequence of the idiocy — a condition of
idiocy resulting from accidental causes. Defec-
tive innervation in all probability led to mal-
nutrition, and predisposed to a tubercular con-
dition. In some this was doubtless materially
assisted by the imperfect mastication and in-
salivation to which the food was subjected.
The tendency to bolt the food unmixed with
saliva often prevents the proper alteration of
the starchy element, so as to fit it for speedy
assimilation.

On the other hand, in a large number of
cases the progenitors had also manifested a

RELATION TO TUBERCULOSIS. 227

tubercular condition; and in some the tuber-
culosis of the parents had been, in my opinion,
the prime cause of the idiocy of the offspring.
I have elsewhere shown (' Lend. Hosp. Reports,'
vol. iii) that a specific phase of idiocy — a phase
which, is curiously associated with altered racial
characters — arises from tuberculosis of tbe pro-
genitors.

The subjects of this class assume the Mon-
golian type ; and while they present a marked
similarity in external conformation, they are
characterised by the same mental and moral
peculiarities ; so that, given a case of the Mon-
golian type, we are often able to trace its origin
to tuberculosis, and to predicate the extent of
response to training that may be expected, and
the tendencies it will evince. Moreover, the
knowledge that is gained by this racial charac-
ter assists in laying down specific rules as to
food, medicine, and general hygiene, without
which the mental development would be but
small. The power of progress is usually much
greater than one would judge by an ordinary
inspection. Such cases are extremely suscepti-
ble to climatic changes, and winter is for them
a period of mental and physical developmental

228 ON IDIOCY AND ITS

rest. In the spring they put forward in-
creased imitative and receptive powers, which
compensate to some extent for the period of
hybernation.

It will be interesting now to ascertain to
what extent tuberculosis exists among the pro-
genitors of idiot children generally. I have
gone through my records very carefully, dis-
regarding all doubtful cases, meaning thereby
cases in which, although there has been a death
from phthisis in the family, I had reason to
believe that it arose from accidental causes, and
selecting only those in which the tubercular
taint was well impressed. I find that in 31 per
cent, of the cases of idiocy which have come
under my care, or about whom I have been
consulted, tuberculosis existed in an unmistake-
able manner, in the family of the progenitors ;
in 6 per cent, the tubercular element was found
on both sides of the family ; in 10 per cent, it
was due to the father ; while in 15 per cent,
the tuberculosis belonged to the mother. It is
a somewhat singular circumstance that while
tuberculosis is more frequent on the maternal
side, the male progeny are the most tubercular.

In the third volume of the ' London Hospital

RELATION TO TUBEEOULOSIS. 229

Reports,' I have endeavoured to show that
idiocy has been too often traced to the inter-
marriage of blood relations, without regarding
other elements that may be operative. It is
readily conceivable that if there be tuberculosis
strongly impressed on a family, the members
of that family would by intermarriage be
taking tolerably effectual steps to ensure the
extinction of their race. Certain it is that in a
large number of the cases in which marriages
of consanguinity are referred to as the cause
of idiocy, the tuberculosis of the progenitors
is a potent, but often disregarded, element.
The Mongolian type, which I have elsewhere
described, occurs, according to my observation,
in greater degree when the tubercular element
is strongly impressed, still more where it exists
in both branches of the family, and greatest if
consanguinity is added thereto.

It appears to me that tuberculosis must be
accepted as one important cause of idiocy ; that
it impresses special characters thereon, charac-
ters which impart a strong family likeness to
the subjects of this class.

It is no less clear to me that idiocy of a non-
tubercular origin leads to tuberculosis. Whether

230 EBLATION OF IDIOCY TO TUBERCULOSIS.

this arises througli the influence of the pneumo-
gastric nerve, mal-assimilation of food, or defec-
tive innervation, it cannot but be regarded that
the connection between these two maladies is
by no means accidental, and that a due appre-
ciation of this relation is necessary to those
who would treat effectively congenital mental
lesions.

A CASE

ASYMMETEICALLY DEYELOPED
BRAIN.

* Trans, Path. Soc.,' 1869.

The brain now exhibited was removed from
the cranium of a girl seventeen years of age,
who had been idiotic from birth. Her father
died insane. Her mother had good bodily and
mental health. She was the youngest of six
children. The other members of the family
had average intellectual powers, but were all
delicate as to their physical health ; one brother
died from phthisis. At the age of seven months
she had epileptic fits, which persisted for some
time at short intervals. She never spoke. The
cutting of her teeth and her walking were both
deferred. She was passionate and self-willed.
She was always in motion, full of mischief, and
delighted in tearing things up and putting them

232 ASYMMBTEIOALLT DEVELOPED BRAIN.

on the fire. Her habits were dirty. Under the
influence of training she became clean, tract-
able, and able to take some part in her own
toilet. She was taught to feed herself with
propriety at table. She made no attempt to
speak, apparently from want of ideas to com-
municate. She would come when called, but
manifested very little affection. Her demeanour
indicated considerable erotic feeling. There
was no paralysis either of sensation or motiou,
and her powers of prehension and manipulation
were susceptible of education.

Her physical health had been very good for
several years, until an attack of scarlet fever
led to acute desquamative nephritis, and conse-
quent broncho-pneumonia.

Post-mortem examination. — The body was
well nourished, and weighed 6 stones 12 lbs.
There was hair on the pubis, but not in the
axillae. The heart weighed 7 J oz., the valves
competent ; the large vessels filled with clots
of blood. The left lung was adherent to the
costal pleura, weighing 14| oz. ; interlobular
adhesions. The apex was much puckered,
corresponding thereto was a calcareous mass
the size of a pea, of a hard density ; another

ASYMMETRIOALLY DEVELOPED BRAIN. 233

part of the apex contained a tubercular nodule
the size of a bean. The posterior part of the
lung was intensely congested. The right lung
was hepatised throughout ^ of its extent. The
bronchial glands were enlarged, and the tubes
intensely injected. The kidneys presented at
the margin of the pyramids a deep red colour.
The uterus and ovaries were normal.

The cranium was slightly unsymmetrical,
exhibiting slight flattening on the anterior third
of the left side. The circumference was 21f
in. ; the antero-posterior diameter 6*5 in. ; the
antern-posterior curve lOf in. ; the bilateral
diameter 5*3 in.; the bilateral curve 7*5 in.
On removing the calvarium the anterior portion,
of the left side corresponding to the external
flattening was found to be enormously thick-
ened.

The left side of the encephalon was conse-
quently much smaller than the right, and on re-
moving the brain it was found that this dis-
parity was still further increased by a diminu-
tion of brain matter on the inferior surface of
the anterior lobe, which was replaced by exces-
sive thickening and consequent elevation of the
orbital plate of the frontal bone.

234 ASYMMETRICALLY DHJVELOPED BRAIN.

The left hemisphere was not more than two-
thirds the size of the right. The occipital lobe
was slightly less developed on the left side than
on the right, but the great cause of want of
symmetry was the absence of development
of the frontal lobe. All the convolutions were
present, but the middle and inferior frontal
gyri were extremely minute in size, although
not more simple than usual. The gyri of the
orbital lobule were also of small size.

Bemarhs. — Asymmetrical brains are not un-
frequently met with in dissections of idiots,
but so great an inequality has never before
come under my notice. There was no want
of symmetry in the lobes of the cerebellum.
In this case it was arrest of growth rather
than of development, as indicated by the com-
plexity of the defective convolutions. The
amount of disparity could not have been pre-
dicated before death by external examination
of the cranium. The thickened calvarium and
orbital plate were sequential to and not ante-
cedent to the arrested growth.

A remarkable case of asymmetrical brain,
which came under my notice a few years
since, had associated with it an asymmetrical

ASYMMETRICALLY DEVELOPED BRAIN. 235

cranium, but the larger side of cranium corre-
sponded to the diminished hemisphere of the
encephalon ; the inner and outer tsibles of the
skull had separated widely, so that external
examination gave no idea of the size of the
skull cavity.

It is worthy of remark that the region im-
plicated was that known as Broca's. Having
regard, however, to the frequency of absence of
speech in idiocy, I cannot look upon this case
as being of much importance in localising the
faculty of speech to one half of the hemisphere,
or to the frontal lobe in particular. The
absence of speech was the result of defect of
cerebration generally. There was no power to
formulate ideas, and speech was not required.
It should also be noticed that she was the
youngest child of a father who died insane.
There is reason to believe that she was pro-
created during the early progress of the mental
alienation, and thus suffered in a way different
from the others, who were born anterior to the
mental change. This is in accordance with
many instances which have come under my
observation, and what might be theoretically
expected.

A CASE

MICROCEPHALIC SKULL.

'■ Trans. Path. Soc.,' 1869.

The cranium exhibited is that of a boy thir-
teen years of age, having a height of 45^ inches,
and a weight of 26 lbs., who died from tuber-
cular disease of the lungs. He was the son of
healthy parents, but had been an idiot from
birth. The cause of idiocy was attributed to
fright of the mother during pregnancy. He
was dirty in his habits, did not speak, and was
extremely mischievous. The circumference of
his head measured 18 inches, the longitudinal
curve 11 inches, the longitudinal diameter 6
inches, the bilateral curve 10 inches, the bi-
lateral diameter 4-8 inches; the brain weighed
2^ lbs. ; the fornix was diffluent, the middle
commissure absent, the right corpus striatum
smaller than the left; the pons Varolii and

MIOROCEPHALIC SKULL. 237

medulla oblongata weighed together | oz. ; the
cerebellum weighed 3| oz., the right lobe being
narrower anteriorly than the left. The cal-
varium, when deprived of integument, measured
17 inches; the longitudinal diameter 5|- inches,
the bilateral diameter 4f inches. The calvarium
was un symmetrical, being larger on the left side
posteriorly, and the left parietal eminence being
more prominent than the right. The anterior
portion of the cranium had a remarkable prow-
shaped prominence, corresponding to the medio-
frontal suture which remained unossified ; all
the remaining sutures were in the same con-
dition.

Remarks. — The above case is interesting, not
as exhibiting a very extreme degree of micro-
cephalism, but as evidence that premature
synostosis of the cranial sutures cannot be
regarded as the cause of the abnormal condition.
In this case, not only were the usual sutures
in an unossified condition ; but the medio-frontal
suture, which usually becomes ossified during
the first year of extra-uterine life, was patent,
so that deferred rather than premature synos-
tosis existed. Moreover, it throws doubt on
the view usually entertained, that scapho-

238 MIOEOOEPHALIO SKULL.

cephalic skulls depend on the premature ossifi-
cation of the sagittal suture, as in this case
the marked frontal ridge corresponded to a
line where synostosis had been remarkably
.postponed.

A CASE

MIOEOCEPHALIC SKULL.

' Trans. Path. Soc./ 1869.

The cause of deformation of the cranium,
and especially of that kind known as micro-
cephalism, has been so authoritatively stated to
be premature synostosis of the cranial sutures,
that the tendency has been to acquiesce in this
explanation and to accept this as the great
determining factor. My own observations on
the crania of about 200 idiots — many of them
deformed in various ways, and some of them
unusually small — have led me to take an entirely
different view, and to assume that the devia-
tions of the cranium have been rather the
sequence of circumstances arresting the deve-
lopment and growth of the encephalon, and
have not been the result of premature ossifica-
tion of the sutures. The only case in which I

240 MICKOOEPHALIO SKULL.

have met with ossification of the sutures was a
case of macro cephaHsm, where certainly the
ossification of the sutures could have had no
influence in the production of the enlarged
cephalic mass.

The cranium which I now produce is interest-
ing, as showing how an extreme degree of
microcephalism can exist without any ossifica-
tion of the cranial sutures. The cranium is
that of a male, eighteen years of age, who had
been educated with some slight result. He had
acquired speech and correct habits, had learned
to be self-helpful, to count, and to make imitative
drawings of a simple character on a black-board.
The head measured in its circumference 15
inches. The antero-posterior curve measured
from the glabella of the frontal bone over the
vertex to the occipital protuberance 8 inches.
The bilateral curve over the vertex from above
the implantation of the ears was 8 inches. The
antero-posterior diameter of the head was 5
inches, the bilateral diameter 3*9 inches.

The greatest antero-posterior diameter of
the interior of the cranium was 4*7 inches ; the
greatest bilateral diameter of the interior of
the cranium 3 "4 inches.

MIOROOEPHALIO SKULL. 241

All the sutures which are usually unossified
were perfectly free from synostoses, and, in
fact, the cranial bones were more than usually
freely separable the one from the other.

It is worthy of remark that more than one
foreign observer had predicated during the
youth's life that it was a good illustration
of premature synostosis. I had been led to
doubt this from the result of former autopsies,
and I am desirous of placing on record
this extreme degree of microcephalism, without
any synostosis, as a striking example in which
other than mere mechanical causes must be
looked for as productive of this and analogous
eases.

U

A CASE

AEEESTED DEYELOPMENT.

♦Trans. Path. Soc.,' 1869.

J. P., a female, aged five, came under my
observation at the London Hospital. She
measured twenty-two inches in height, was un-
able to walk, but could stand by the help o£ a
chair. She could not speak, and gave utter-
ance only to a few monosyllabic sounds. There
was no deformity of the body or limbs. The
face had an earthy complexion, and the integu-
ment generally had a wrinkled appearance as
if it were too large for the diminutive body.
The hair was sparse and coarse, the eyebrows
obliquely placed, the tongue large and rugous.
There was a SDiall tumour on each side of
the neck above the clavicle. She understood
what was said to her, and had the mental con-
dition of a child about fifteen months old. The

AERESTED DEVELOPMENT. 243

father and mother had been healthy, and there
was no history of mental or physical deviation
on either side. The mother stated that her
first child was perfectly healthy, until it died
from measles. The husband about that time
gave himself up to intemperance, and the
mother subsequently gave birth to a child,
which died at the age of three, having the same
physical peculiarities as the subject of these
remarks. The third child, now under con-
sideration, was procreated like the second,
while the husband was suffering from alcoholic
intoxication. A miscarriage succeeded. The
husband at this time relinquished his habits of
intemperance, became as thrifty and prudent
as he was formerly the reverse ; and the wife
again becoming pregnant, gave birth to a child
normally developed, and in good bodily and
mental health, now sixteen months old.

Remarks^ — The above case is of great interest,
because, in the author's opinion, it adds another
to a group of cases which have come under his
observation of arrested development arising
from intoxication of one or both of the pro-
genitors at the time of the procreative act.
The whole group of cases has presented features

244 AEEESTED DEVELOPMENT.

of such close resemblance that it is difficult to
avoid the conclusion that there was some unity
of cause, and careful investigation has elicited
facts bearing on the etiology of these cases,
having a close parallelism to the circumstances,
which he believes to have been potential in
this. He has known some of these cases to
attain the age of twenty, while still preserving
infantile characteristics.

In each case the tumours in the neck have
been observed.

A CASE OE PAEALYSIS

APPAKENT MUSCULAR HYPERTROPHY.

♦Path. Soc. Trans.,' 1870,

Benjamin Round, aged eleven, admitted into
tlie London Hospital, September 14tli, 1869.

History. — His mother states that this disorder
has been coming on for five years. The first
thing wrong which she noticed was, that when
he fell down he could not get up again. About
two years ago he began to get unsteady in his
gait ; when running, if he tried to stop himself
suddenly, he fell down, and even when walking
he had difficulty in stopping without tumbling
over. Running was easier to him than walking,
and walking than standing still. When he stood
still, he looked out for something to lean against,
getting to the wall if he could. His mother
noticed that as he ran he used to stick out his

246 PAEALTSIS WITH APPARENT

belly and throw back his shoulders. For the
past twelve months he has been nnable to walk,
and for the past seven months has been gradu-
ally losing the use of his arms.

Family history. — His mother's health has
always been good, and so has his father's. No
history of any hereditary disease, except that
his grandfather died from " consumption," and
his father's grandfather was insane. All his
brothers and sisters are healthy.

The only previous illness the boy has had
was measles seven years ago. Has never had
thrush nor any cutaneous eruption. Has had
thread-worms for six years. His mother suckled
him for eighteen months. He was not any
longer teething or learning to walk than the
other children. He has always been very fat ;
his belly has always been big, and the calves of
his legs have always been large. During the last
four years his mother thinks his ankles and
thighs have wasted. His head is unusually
large. During the past two years he has not
been well fed ; the family have only had meat
once a week, and then a pound and a half
divided among ten.

Present condition. — He is utterly unable to

MUSCULAR HYPERTEOPHY. 247

stand. When put upon his legs they sprawl
helplessly in every direction. He can sit up,
but if he is gently pushed back he falls quite
passively upon the floor, and can by no efforts
raise himself. As he sits up, he likes to sup-
port himself by using his hands as props. When
pushed back in bed against the pillow, so that
he does not fall quite down, he can manage to
raise himself by swinging his head laterally to
the front. There is great loss of power over
the arms. On being desired to raise his arm
slowly, he can move it but a little distance from
his side, and that by the aid of his scapular
muscles, the shoulder being raised and thrown
forward, and the lower angle of the scapula tilted
upwards and outwards. By a jerk he can raise
it about 60 degrees, and by swinging his arm
backwards and forwards, he can get it up nearly
horizontally. If his arm be extended in the
supine position he can flex it at the elbow-joint,
but if a small book be placed in his hand he
cannot raise it. If his arm be flexed at the elbow
he can extend it, but a weight of three or four
ounces prevents his doing so. He can perform
any movements with his fingers and thumb, but
without much power. When he wishes to raise

248 PAEALYSIS WITH AFPAEENT

his hand lie does so by the aid of his fingers,
jnaking them climb, as it were, over his body
and head, and drag his arm after them. He
separates his fingers, and places his thumb on a
higher point than the rest ; he then approxi-
mates his fingers, and resting his little finger on
the same level as his thumb, again separates his
fingers, and plants his thumb on a higher level
still ; in this way he makes his arm travel to the
•desired place. He cannot flex the thigh upon
the trunk at all in bed ; out of bed ha can do it
a little. As he lies in bed he moves his lower
extremities about by the movements of his feet,
alternately using the heel and toe as a fixed point
to advance the rest of the foot. He can rotate
the limb at the hip- joint. Out of bed, by
swinging his legs, he can get them to an angle
of about forty-five degrees from the perpen-
dicular, but he cannot keep them in opposition
,to the force of gravity. He can also swing his
feet laterally. He can move his feet a little
laterally at the ankle-joint, but without much
power. He flexes and extends his toes readily.
He can adduct the limb slightly, but appears to
do so by the action of his quadriceps.

Muscular system ; loiver extremities. — The

MUSODLAE HYPBRTEOPHY. 249

muscles supplied by the gluteal and great sciatic
nerves are immensely hypertrophied^ On look-
ing at the boy the prominence of his gluteal
region is very apparent, and on feeling the part
the extreme hardness of the. muscle is very
striking. The lumbo-sacral curve is greatly
exaggerated. The tensor vaginae femoris can
be felt as a thick, hard, firm band under the
skin. The flexors of the thighs are also much
hypertrophied. The muscles of the calves are
also very hard and very large. The extensor
and peronei muscles on the outside of the tibia
appear to share this hypertrophy. The foot is
in a state of talipes equino-varus.

The adductor muscles on the inside of the
thigh are very soft, small, and lax. The quadri-
ceps extensor appears somewhat hypertrophied,
but it is very diiBSicult to estimate its size. The
sartorius is wasted.

Measurements of lower extremities —

From one iliac spine to the other . = 8 in.
Around pelvis, over most prominent

part of glutsei . . . . = 24J in.
From anterior superior iliac spine

to outer condyle. . . . = 12| in.

250 PARALYSIS WITH APPARENT

From great troclianter to outer con-
dyle = lOf in.

Circumference at middle of thigH . = 12 in.
, Tibia, from inner tuberosity to inner

malleolus . . . . . = 9J in.

Circumference of thickest part of

leg = 11 in.

Circumference of leg just above

ankle . . . . . . = 6 in.

Upper extremities. — The deltoid seems a little
hypertrophied, but not so much as the glutsei.
The triceps seems also somewhat hypertrophied.
The pectorals and scapular muscles almost com-
pletely atrophied, and the latissimus dorsi can
scarcely be felt. The head of the humerus can
be felt with perfect ease, and can be partially
dislocated and reduced, the ligaments being very
lax ; the bony points around the joint can
be very easily felt. The biceps and coraco-
brachialis are also very much wasted. The
muscles of the forearm and of the thumb and
fingers are fairly developed, and of their natural
size.

MUSCULAR HYPERTROPHY. 251

Measurements of upper extremities —

From acromion to outer condyle . = 8 J in.

Circumference at middle of arm . = 6 in.

Length of ulna . , . . = 7 J in.
Circumference of forearm just below

condyles . . . . , = 6f in.

TruTik. — As before said, the lumbo-sacral
curve is greatly exaggerated. The erector
spinse is immensely hypertrophied, and can be
felt as a thick, hard mass on each side of the
spine. The spinous processes of the vertebrae
lie in a groove between these masses of muscle.
In the space between the crest of the ilium
and the last rib the thick hard edge of the
erector spinse can be felt distinctly. The belly
is big, but the muscles forming its wall do not
appear to be either wasted or hypertrophied.
The cremasters act readily. The chest is
broad and deep, and the costal angle exceed-
ingly obtuse ; its conical shape can be very
distinctly seen, owing to the wasting of the
pectorals. The serratus magnus is large, and
its serrations can be seen with great clearness
through the skin ; it is not hard, like the
erector spinse, but appears to act naturally.

252 PARALYSIS WITH APPARENT

The action of the diaphragm in respiration
was carefully watched, and found to be the
same as in a healthy person. The intercostals
appear to act fairly.

Measurements of chest —

From acromion to acromion . = 10 in.
Circumference just below axilla :

On expiration . . . = 24 in.
On inspiration . . . = 25 J in.
Circumference on a level with
ensif orm cartilage :

On expiration . . . = 26 in.
On inspiration . . . = 274 i^*

Head and neck. — The sterno-mastoid is
rather wasted. The depressors of the oS
hyoides are capable of fairly vigorous action.
It is doubtful whether there is anything
abnormal with the trapezius, and the other
muscles of that group ; if anything they are
hypertrophied. His temporal muscles are un-
doubtedly hypertrophied, and, seen from the
front, form a small tumour outside each orbit.
His masseters seem somewhat increased in size,
but this is difficult to ascertain. The facial

MUSOULAE HYPERTROPHT. 253

muscles of expression appear sluggisli in
their action. His orbiculares are wasted. ; lie
can shut his eyes, but cannot screw them up
tightly. He cannot frown, and can elevate
his eyebrows but little. The muscles acting
on the mouth do not seem defective at first
sight, but on making him go through various
grimaces, it is seen that he has not the com-
mand over the upper 'lip that he has over the
lower; this, perhaps, is from misapprehension
of directions. He puts out his tongue in a
peculiar way, it always being concave, and
he does not protrude it beyond his lips unless
told to put it out further, when he makes an
effort J but it is never convex from side to
side. No affection of any ocular muscle.

General appearance, Sfc. — He is a dull, heavy-
looking boy, with a stolid, but somewhat
cunning expression of countenance. His face
is very fat, especially about the lower part ;
complexion sallow and pasty ; skin thick,
superficial veins cannot be distinctly seen
through it. His head is very large (circum-
ference where the hat fits twenty-one inches) ;
its shape is broad rather than long. Hair
thick, brown, and straight. Forehead rather

254 PARALYSIS WITH APPAEENT

high. Eyes brown, pupils large, eyelashes
long, eyebrows thick at outer part, thick
towards the median line. Nose flat and broad,
especially broad at the bridge ; alse nasi thin,
nasal aperture large. Ears small, but well
shaped, lobules not ill developed. Lips thick,
upper lip thicker than lower, angles of mouth
somewhat inclined downwards. Thyroid gland
enlarged but not greatly. Yoice natural, clear,
low-pitched. Bones of extremities well shaped ;
epiphyses not unduly large.

Mental condition. — He is stupid or dull, but
rather cunning. He is generally good tem-
pered, but is often passionate, and at times
very sulky ; he appears to possess a strong
will (he has probably been spoilt at home).
He is not timid or bashful in any way. He
smiles when spoken to, answers questions
readily, and he takes any experiments tried
upon him in very good part. He cannot read,
but knows his letters. He has an appreciation
of music, and amuses the other patients by his
singing, whistling, &c.

Nervous system. — He sleeps well. Has no
fits or cramps of any kind. Sight good,
ophthalmoscopic appearance normal. Hear-

MUSCULAR HTPEETEOPHY. 255

ing, taste, and smell good. Sensation, both
painful, tactile, and thermic, appears to be very
good all over the body. It cannot be estimated
with the compasses, because the boy, whether
from laziness or any other motive, does not
(or perhaps cannot) give consistent answers.
The atrophied muscles do not respond at all to
electricity. The gastrocnemii and hamstring
muscles contract under it. The other hyper-
trophied muscles were not tested with it.

Digestion and appetite good. Bowels regular.

Urine. — Sp. gr. generally rather high ; acid ;
no albumen, no sugar.

Respirations f 18 per minute, taken minutely ;
no cough or dyspnoea.

Heart. — Cardiac dulness. reaches above to
third rib ; on the right to an inch beyond the
sternum ; on the left to within half an inch of
nipple; apex beat under fifth rib, one inch to
right of nipple, 88 per minute. Impulse nor-
mal. Sounds sharp and clearly defined, some-
what exaggerated. J^o murmur or thrill of
any kind.

Temperature, taken at different times, always
normal.

Remarks. — This case, for the very careful

256 PAEALTSIS, ETC.

notes of wHcli I am indebted to my clinical
clerk, Mr. Herman, is a very typical example
of the disease so well described by Dr. Du-
cbenne in the ' Transactions ' of this Society.
By the aid of the harpoon I extracted speci-
mens of the muscle from both gastrocnemii.
When examined by the microscope, it was
noticed that the transverse striation of the
muscular fibre was very indistinct, that there
was a, great increase of connective-tissue ele-
ments, and that there were numerous fat-
globules, but they were distinctly external to
the sarcolemma. There was no fatty degene-
ration of the muscular structure.

The treatment has been dietetical with the
daily use of the faradic current. No im-
provement, however, has resulted. I think the
best name for such cases is pseudo-hypertrophic
paralysis.

A CASE

PSEUDO-HYPERTROPHIC PARALYSIS.

' Path. Soc. Trans.,' vol. xxi, 1870.

Samuel Richardson, aged eleven, admitted
into the London Hospital 22nd February, 1870.
There is no family history of insanity, nor any
mental affection. The father appears a man
of average intelhgence ; the mother is certainly
below the average. She appears a woman of
a desponding, irresolute disposition, and of
very slow perception; I should think her in-
clined to melancholia. She is thirty-seven,
and has had six children ; this one is the
eldest. It was born at full time, after a
tedious labour, lasting two days and a half,
and was delivered with instruments. She has
had one miscarriage, and one child, her fourth,
died aged one year and a half, from " fits,"

17

258 PSEUDO-HYPERTROPHIO PAEALTSIS.

whicli it had had from a month old : at the
time it died it had not cut any of its teeth.
All the rest are living. She states that while
pregnant with this child she was in very deli-
cate health, but she is unable to describe any
definite ailment. She has always had plenty
of food. The father is a mason, aged thirty-
three; has always had good health. During
the first two or three years of his marriage he
used to be very frequently intoxicated. This
child was two years old before he had any teeth,
or before he could walk, and he was always very
fretful. The mother says that while he was
teething, and afterwards, he used to suffer from
attacks of " inflammation," but I cannot make
out what she means by this. She does not
think that in intellectual capacity he is behind
the other children. Five years ago he had
rheumatic fever; was in bed six months, all
his joints being affected. Previous to that was
quite well. Since then has suffered at times
with rheumatic pains in different joints, and
has been weak and delicate. About twelve
months ago his parents first noticed that when
he walked he used to " bend his back in ;" his
stomach sticking out in front and his buttocks

PSEUDO-HTPEETROPfllO PARALYSIS. 259

behind. About nine months ago it was first
observed that when running, his legs would
give way, and he would fall with his legs under
him. About eight months ago he began to
complain of his back hurting him. About this
time, his mother says, he began to lose strength
in his arms. His walking has since gradually
got worse; he began to be unable to run
before he was unable to walk. His falls be-
came more and more frequent; at last he would
fall down about every five or six yards. For
the past two months he has been unable to
walk without assistance, and for the past fort-
night has been unable to walk at all. For
some time past, his mother says, he has been
losing flesh. She says he has lost flesh in his
calves and buttocks as well as in other places.

He is rather small for his age. His height
is 3 ft. lOJ in. His aspect is that of a dull,
backward child. He has a vacant, apathetic,
timid expression of face. Complexion fair,
cheeks fresh-coloured ; hair brown, thick,
straight, and fine ; eyelashes long and fine ;
eyebrows thin, a wide interval between them
in the middle line. Pupils large, irides
dark, sclerotics of a bluish tint; eyeballs

260 PSEUDO-HyPEETROPHIO PARALYSIS.

prominent. Nose broad, especially at tlie
bridge, al93 nasi tliick; nasal apertures large.
Forehead high, round, protuberant; face fat,
especially at lower part ; lips tlaick, upper lip
the thicker, and is broad and long. Bones
well shaped ; epiphyses not unduly large.
Finger ends square. Costal angle acute.
Palatal arch contracted; teeth crowded and
irregular; skin thick, superficial veins can be
seen, but not distinctly. Ears of moderate
size, lobules small. Circumference of head
where hat fits, 20J inch.es.

He cannot stand by Mm self. When told to
try and. stand by himself, he bends forward,
and stands on tiptoe, but he cannot succeed.
If he be held up by the arms there is a
tendency to bend his body at the hips. If he
be made to put his heels to the ground the
tendency is greater. If left unsupported, his
body bends forward at the hips, and he falls
witb his legs under him ; but he can stand if
support be given by the hand pressing his
buttocks forward, though he does so in a
tottering way. He can sit up without assist-
ance, but he likes to have one hand behind him
as a kind of prop. If he be laid down on his

PSEDDO-HYPERTROPHIO PARALYSIS. 261

back, he cannot get up by himself without
great exertion ; he accomphshes it by turning
on his side, and by pulling at the clothes
brings his body to the proper angle with his
legs, he then clutches at the bedclothes and
pulls himself up by them.

His body is wasted, but not markedly so..
The lumbo-sacral curve is slightly exaggerated ;
the gluteeal region is larger and more rounded
than is consistent with his wasted condition,
and it is very hard. The erector spinas is
about as large as it should be for a boy
of his age, but is much harder and firmer
than it ought to be. The abdomen is large.
It is difficult to estimate the size of the abdo-
minal muscles, but they are capable of fairly
vigorous action; (measurement around pelvis
over most prominent part of glutsei, twenty-
two inches ; from one iliac spine to the
other, eight inches). He moves his legs
about badly, and without much power. If
asked to cross his legs, he takes hold of one
with his hands and lifts it over the other.
He can perform this movement without the
aid of his hands, but does so slowly, and
with apparent exertion. As he lies on the

262 PSKUDO-HYPEBTROPfllO PAEALYSIS.

bed, if told to draw up his legs, he does this
with more force than he can any other move-
ment. On sitting him on the edge of the bed
he can raise his feet to a right angle with his
body, i. e. extend his knees ; but a 1 lb. weight
attached to his great toe is suflScient to prevent
him. On placing him on his face, he can flex
his leg on the thigh, but a 2 lb. weight attached
to his great toe prevents him. He can move
his feet laterally at the ankle-joint, and does
this pretty well. He can extend and flex his
foot a little at the ankle, but he does not do
this nearly so well as he should. He can
move his toes but slightly.

On examining the muscles, the tensor vaginse
femoris is felt enlarged and very hard. The
sartorius he can put in action, and it does not
seem wasted. The quadriceps extensor seems
harder than it should be, but this is diflficult to
estimate, as is the size of the muscle. The
flexor muscles of the thigh are larger than
ordinary. The adductors are small, but con-
tract well when he puts them in action. The
gastrocnemii are large and very hard ; the
extensor muscles and the peronei are also hard,
and are certainly not wasted. The foot is in

PSEUDO-HrPERTROPHIO PARALYSIS. 263

a state of talipes equino -varus : the tendo
AcMUis is very tense. The extensor brevis
appears wasted, but it is difficult to tell.
{Measurements. — From trochanter major to
external condyle, lOf inches ; from anterior
superior spine of ilium to external condyle
12 J in. : circumference at middle of thigh,
9^ in. ; length of tibia, from inner tuberosity
to inner malleolus, lOJ in. ; circumference at
thickest part of calf, 8f in. ; just above ankle,
H in.)

His chest is long and narrow ; costal angle
very acute. Breathing mostly abdominal.
When told to take a deep breath, he does so
with his diaphragm; the chest moves but
slightly, and the intercostal spaces sink in.
The serratus magnus can be felt, and appears
about normal.

He can move his hands and arms in any
direction, but has not much strength in them.
He can take a 2 lb. weight and elevate it above
his head, but no heavier weight. A boy aged
nine, in the same ward, suffering from pul-
monary disease, can lift 6 lb. ; on resisting the
action of the triceps with a 2 lb. weight, he can
just extend his arm. As to the biceps, he

264 PSEUDO-HYPERTROPHIO PARALYSIS.

cannot flex his arm against 2 lb., but he can
against 1 lb. He can move his fingers readily,
but has not much strength in them.

On examination of the muscles, the pectorals,
biceps, and coraco-brachialis are most markedly
wasted. The deltoid is hypertrophied, also
the triceps, in a very noticeable manner. The
latissimus dorsi is wasted, also the sterno-
mastoid, very decidedly. The scapular muscles
are hypertrophied, as is the trapezius. The
muscles of the forearm and hand seem neither
hypertrophied nor wasted. {Measurements.—
Circumference of thorax : just below axillge,
on inspiration, 20J inches, on expiration,
20J in. ; at level of ensiform cartilage, on
inspiration, 23 J in., on expiration, 22^ in. ;
from acromion to acromion, 10 in. ; from
acromion to outer condyle, 8^ in. ; circumfer-
ence at middle of upper arm, right, 5f in. ;
left 6|- in. ; length of ulna, 7 j in. ; circumfer-
ence of thickest part of forearm, 6 in. ; circum-
ference of neck, 10 J in.)

His facial muscles of expression appear slug-
gish in their action. He can screw his eyes
up firmly, and can elevate his eyebrows ; but I
cannot get him to frown ; whether he can or

PSEDDO-HTPERTEOPHIC PARALYSIS. 265

cannot I do not know. He seems to have but
little power over his lips. His face seems re-
markably devoid of expression ; on trying to
make him grimace, he either will not or cannot
contort his face as told. When he laughs he
does so in a feeble sort of way ; I cannot make
him laugh aloud, or put on a broad grin, but
the other patients say that he does. His tem-
porals and masseters seem normal. His thy-
roid gland does not seem enlarged. He puts
his tongue out in a feeble manner; he puts it
out slowly, and a very little distance, but he
can put it out far if he likes.

Mentally he is certainly below the average
of a boy of his age. He is very slow in his
answers ; seems afraid of everyone, and often
cries. The men in the ward remark that the
other boy (Round), although more paralysed,
is " the best man of the two." He knows his
letters, but cannot read. He can do very
simple sums in arithmetic, such as that two
and two make four, but three and four he says
make eight. He is cunning, although stupid.

He sleeps well. Has no fits or cramps of
any kinds. No paralysis of any ocular muscle.
Fundus oculi normal. Hearing, taste, and

266 PSEUDO-HYPERTROPHIO PARALYSIS.

smell good. Sensation of every kind, painful,
tactile, thermic, and electric, seems unim-
paired : he does not answer properly, so that
it is impossible to estimate it for purposes of
comparison. Induced electricity applied to
muscles does not produce contraction.

Appetite and digestion good, bowels regular.
. Urine. — Sp. gr. about 1020 ; acid, no depo-
sit, no albumen, no sugar.

Pulse 96. Cardiac dulness extends above to
third rib; on the right, to right margin of
sternum; on the left, to half an inch beyond
the nipple ; below, to the sixth rib. Apex-beat
under fifth rib, half an inch to the right of the
nipple. The impulse is increased, but is not
heaving, nor is there a thrill. The first sound
is doubled, but there is no decided murmur.

Respirations 20 per minute. No cough, no
dyspnoea. Temperature normal.

Bemarhs. — This case presents a very good
example of pseudo-hypertrophic paralysis in an
earlier condition than that of " Eound," pre-
viously reported. I am again indebted to my
clinical clerk, Mr. Herman, for the very care-
ful notes of the case. I did not extract any
specimens of muscle, in consequence of rather

PSEUDO-HYPEETEOPHIO PAEALYSIS. 267

troublesome wounds having been produced in
tbe previous case.

It is worthy of being noted that this is the
seventh case of pseudo -hypertrophic paralysis
which has come under my observation, and
that in each case there has existed more or less
mental feebleness.

The treatment has been dietetical, with the
daily employment of faradisation. No per-
ceptible improvement of any kind has been
observed.

268 EELATION OP THE TEETH AND

ON THE RELATION

TEETH AND MOUTH TO MENTAL
DEVELOPMENT.

' Trana. Odontological Soc.,' vol. iv, 1871-2.

Gentlemen, — When your President did me
the honour of requesting me to read a paper
before your Society, I felt at first some reluct-
ance, from the consciousness that one of a very
practical character was not within the scope of
my power.

It occurred to me, however, that there was a
branch of inquiry in which I felt considerable
interest, and which had some slight bearing on
the department of medical science represented
by this Society. I thought, moreover, that I
should derive great gain myself in bringing my
observations before you, from the fact that

MOUTH TO MENTAL DEVELOPMENT. 269

while some of my work has been with a some-
what special class of humanity, you would be
able to correct or confirm my views from obser-
vations over a wider and more varied field. It
is thus, by the comparison of results obtained
from opposite standpoints that broad princi-
ples may be elicited, where otherwise narrow,
and possibly mistaken, views might be enter-
tained.

At an early period of my study of the mental
affections of childhood and youth, I became
convinced that the question involved a far
larger region of inquiry than the mere psycho-
logical phenomena which were presented before
me, — that, interesting as were the examples of
mental deviations which were the every-day
object of one's contemplation, they were really
only a part of the great subject ; and one be-
came convinced, from observation, that the
physical deviations were as interesting and
important as the psychical, in relation to the
study of mental alienation, and especially to
that form of it which had a congenital origin
or proclivity. It became clear to me that idiocy
and imbecility were not simply disturbances of
brain-power, — were not simply nerve-lesions in

270 EELATION OP THE TEETH AND

the narrowed acceptation of the term, — but
were profound diseases involving almost every
organ and system of organs in the body. True,
the encephalic ganglia were found altered,
either in quality or quantity, or both ; the con-
volutions of the brain might be reduced to
quadrumanous simplicity in one case, or pre-
sent remarkable symmetricality in another;
but these were conditions that could only be
ascertained on post-mortem inspection. The
question that presented itself to me was, —
Were there any outward and visible signs of
inward mental disturbance? If idiocy were
something more than brain alteration, it followed
that an inquiry into the condition of the other
organs might establish some correlative change
in them. With this object in view, I made a
careful investigation into the bodily condition
of nearly a thousand feeble-minded youths —
their height, weight, and bodily conformation ;
into the condition of their muscular develop-
ment, the state of their eyes, the shape of their
ears ; and last, but not least, into the structure
of their mouths and the contents of the oral
cavity. It was in my inquiry into the condi-
tion of the teeth and mouth especially that I

MOUTH TO MENTAL DEVELOPMENT. 271

arrived at the conclusion that, in by far the
larger number of instances, I was able to indi-
cate the period at which the depressed condi-
tion commenced and to predicate in some degree
the amount of improvement which physical,
intellectual, and moral training might possibly
effect.

Thus an examination of the mouth afforded
me a valuable guide both as to diagnosis and
prognosis in cases which, without such guide,
would be surrounded with insurmountable
difficulty.

In consultations one is often pressed by the
friends of the patient for an opinion as to the
date at which the affection commenced. It is
always a relief if an opinion can be given that
the child was born intelligent ; that the calamity
is the result of some after-birth catastrophe.
Curiously enough, there is often a degree of
wounded pride if it is decided that the child was
defective from birth. It is by an appeal to the
physical conformation only that the decision can
be justly made. In children whose idiocy is
accidental, arising from causes operating after
uterine life, there is but slight deviation from
normal condition in the state of the mouth and

272 RELATION OF THE TEETH AND

teeth while it is in those whose malady is con-
genital, especially where arising from causes
operating at a very early period of embryonic
life, that the deviation of the mouth and its
appendages from the normal condition is most
pronounced.

It often happens to me to see children, about
whom the only anxiety is that they do not speak.
The parents seek for an explanation in the con-
dition of the palate, little suspecting that the
palatal deformity is only one of the manifesta-
tions of a congenital mental defect, in which
ideas are so little formulated that language is
not needed.

I could occupy a large portion of the time
of this meeting in illustrating the value of an
appeal to the condition of the mouth as an aid
to diagnosis in such cases ; a few cases must
suffice.

A year or two since a very intelligent medical
practitioner in the country was called in to treat
a case of infantile convulsions. The condition
of the child was desperate. He poured from an
ewer a stream of cold water over the occiput of
the child; the convulsions ceased, the patient
was rescued from impending death, but grew up

MOUTH TO MENTAL DBVELOl'MENT. 273

to be an idiot. The friends of the child took up
a position which involved a trial in a court of
law, equivalent to an action for malpraxis
against the medical man. By a judge's order,
I, with other medical men, saw the child ; and
we were ahle to say not only that the child
was an idiot then, but, by an examination of
the mouth, to assert that the idiocy was em-
bryonic as to date, that the convulsion was an
epiphenomenon, and that the medical man was
in no way responsible for the mental condition
of the child whose life he had rescued. Thus,
by an appeal to physical conformation, we were
able to date the mental defect, and to save the
reputation of a medical brother from undeserved
opprobrium.

It will be within your remembrance that this
town was some years since greatly moved by a
sensational trial before a Master in Lunacy, in
which an attempt was made to save from himself
a youth with an honoured name. " Liberty of the
Subject " was the popular cry, and after conflict-
ing evidence, the popular will prevailed, and the
free agent went rapidly to his doom. The
counsel for the defence, in specious terms sug-
gested that the mistake about this young man's

]8

274 DELATION OP THE TEETH AND

imbecility arose f roiQ a defect in his mouth, from
which imperfect speech resulted. I showed at
that time — too late, however, to influence the
verdict — that that was the most important
admission that could be made, — that, given any
amount of mental obliquity, no stronger con-
firmatory proof could have been adduced of his
imbecility than the physical defects of mouth
to which this lisping speech was due. The
sequel proved the true nature of the case.

No less valuable, however, is a study of the
condition of the mouth as a means of prognosis
in any given case. In children who exhibit any
want of mental power, or present anomalous
moral or intellectual symptoms, no more anxious
question is suggested than that relating to
their probable future. The disposition of pro-
perty, and other family arrangements, depend a
good deal on the answer which is given. We
have learned by experience this important fact,
that the child who has been born with defective
intellect is more susceptible of improvement
by physical and intellectual training than the
child who has been born with full possession
of his brain-power, and has afterwards lost it.
It follows, that of two children who are the

MOUTH TO MENTAL DEVELOPMENT. 275

subjects of solicitude, other things being equal,
there is greater probability of improvement
for the patient with an ill-developed, than
the one with a damaged brain. Often it hap-
pens that a microcephalic idiot, about whom
the inexperienced would entertain no sort of
hope, will far outshine, under intellectual train-
ing, the fine, well-developed boy the mem-
branes of whose brain have been the subject
of inflammatory lesion, and about whose capil-
laries lymph has been inextricably effused. An
appeal to the condition of the mouth is an
important aid in determining whether the
lesion on which the mental weakness depends is
of intra-uterine or of post-uterine origin. In the
event of the mouth being abnormal, it indicates
a congenital origin ; while if the mouth be well
formed, and the teeth in a healthy condition,
it would lead to the opinion that the calamity
had occurred subsequently to embryonic life.

Of course, our judgment would be formed
after a physical examination of every organ —
of the condition of the ears and eyes — of the
shape of the cranium; but what I want to
enforce is, that most important information is
derived from an examination of the mouth.

276 RELATION OP THE TEETH AND

I have had this day brought to me a young
girl of manifestly defective power, and the
parents were extremely anxious to know
whether it was a congenital case. Their anxiety
was based partly on an unwillingness for
either branch of the family to allow that
there was on their side any hereditary tendency
to mental disease — a sort of rivalry as to the
purity of the two antecedent sources ; but
mainly also to ascertain with what degree of
fear they must watch the development of their
other children, and how it might affect the
education of their sons, or the marriage pros-
pects of their daughters. JSTo study of the
mental phenomena themselves would have en-
abled me to venture an opinion ; but an exami-
nation into the totality of the physical confor-
mation in general, and of the mouth in particular,
enabled me to refer the calamity, with a con-
siderable degree of certainty, to an accidental
cause, probably a sunstroke in the tropics ; to
clear the other members of the family from the
suspicion of insane proclivity, and to defend the
purity of the rival stocks.

Let us now consider what are the conditions
of the mouth associated with mental defect.

MOUTH TO MENTAL DEVELOPMENT. 277

The lips are usually thick, the thickness being
greatly more marked in the lower than in the
upper one. In addition to the thickening, they
are often striated, marked by transverse fissures;
this character is more generally seen in a class
of congenital idiots, which I have elsewhere
described as Mongolian idiots, from their resem-
blance in physical character to the Mongolian
race. Often the lips are deficient in muscular
power, which interferes with their prehensile
function, and which also induces a tendency for
the saliva to run over the chin. The mucous
membrane is extremely liable to chronic inflam-
mation, and ulceration is induced by the slightest
pressure against prominent or uneven teeth.
The glands of the mucous membrane of the
mouth generally, as well as the salivary glands,
are usually hypertrophied ; and this is another
factor in the production of stammering.

There is a marked postponement in the evolu-
tion of the first teeth. Looking over my notes
of a very large number of cases, I find that the
first dentition is almost invariably postponed.
The ease with which dentition is effected varies ;
sometimes the teeth are cut so easily that no
disturbance of the general health is observed ;

278 RELATION OF THE TEETH AND

in others it is tlie period at wliich. violent
convulsive attacks are developed, imperilling
greatly tlie feeble mental endowment of the
child. Contrary to the law that tissues which
are slowly formed are the most persistent,
these primary teeth have a more temporary
existence than usual. They are frequently
dark, speedily become carious, and their stunted
growth often aggravated by the incessant
grinding of the teeth, which is so frequent
during the infantile life of such children. I have
been curious to ascertain the cause of this
grinding. In most cases it appears to be a
kind of automatic movement, not depending on
the direct influence of the will ; one of those
rhythmic movements of which there are several
amongst children of this class. In others it
would appear to be purposely developed to
produce a monotonous sound, which imparts
pleasure to the feeble-minded. Not only, how-
ever, are the primary teeth ill developed ; they
are often irregularly developed as to sequence.
Nothing but disorder is noticed in their succes-
sion.

Just as the evolution of the temporary teeth is
accompanied by cataclysmic effects, like pheno-

MOUTH TO MENTAL DEVELOPMENT. 279

mena not unfrequently accompany the evolution
of the permanent teeth. The epileptiform con-
vulsions which accompany the first, not nnfre-
quently after a long interlude, reappear at the
cutting of the second, to be followed by another
interlude, and a recurrence at puberty. I have
now under my observation a boy whose first
teething was marked by paroxysmal phenomena
of the most violent kind, which ceased when the
physiological effort was over. He has now
arrived at the period of second dentition, and
the evolution of every tooth is accompanied by
well-marked epileptic attacks and by a corre-
sponding decadence in his stunted mental
development.

The evolution of the second teeth is also fre-
quently postponed, and there is slight irregu-
larity in the sequence of their development. A
marked character of the teeth is their irregu-
larity as to position. They are often crowded —
so crowded as to present their sides instead of
their anterior surfaces. They are often arranged
on different planes. The canine teeth are fre-
quently unduly prominent, and a marked sulcus
is sometimes seen between the incisors and
canines, with prominence of the incisors. The

280 RELATION OF THi<] TEETH AND

teeth themselves . present very frequently a
honeycombed appearance, from an absence of
continuity in the enamel, and they undergo
speedy decay. Nothing is more marked than
the temporary nature of the so-called perma-
nent teeth.

It has been a matter of considerable interest
to me to ascertain how frequently the syphilitic
teeth, so well described by my friend and col-
league Mr. Hutchinson, were to be met with
among the feeble-minded; but the result of
my inquiry has been to discover very few
among them who were in this way indicated
to be the subjects of congenital syphilis. Yery
few have had syphilitic teeth ; but where I did
discover them, I always had confirmatory evi-
dence of the syphilitic history of the case,
and the condition of the teeth was always
associated with the chronic inflammation of
the cornea to which Mr. Hutchinson has called
attention. I have therefore been led to the
conclusion that syphilis is not by any means
an important factor in the production of con-
genital mental disease. The honeycombed teeth
are, I am persuaded, perfectly distinct from the
syphilitic, and are manifestations of that grave

MOUTH TO MENTAL DEVELOPMENT. 281

perversion of nutrition which implicates, in
these cases, every tissue in the body.

The tongue presents peculiarities worthy of
notice. It is frequently unusually large. Its
inordinate size generally arises from increase in
length, and also from an absence of muscular
tonicity. The surface is often curiously corru-
gated, presenting numerous fissures. The sur-
face is rendered still more rough from hyper-
trophy of the papillse. Not only is the tongue
inconveniently large, it is but feebly under the
influence of the will. There is a want of co-ordi-
nation in its muscles ; so that not only is the
more intelligential act of speaking performed
awkwardly even when there are ideas to be
communicated, but the simple voluntary act of
conveying the food to the posterior part of the
mouth, where the reflex act of deglutition is
excited, is eff"ected with difiQculty, and thus an
almost instinctive act is rendered to some extent
abortive.

Of most significant value, however, is the con-
dition of the palate. I have made a very large
number of careful measurements of the mouths
of the congenitally feeble-minded and of intelli-
gent persons of the same age, with the result of

282 EELATION OF THE TEETH AND

iDclicating, with some few exceptions, a mark-
edly-diminislied width between the posterior
bicuspids of the two sides. The exceptions
were some few cases of macrocephahc idiots,
who had inordinately large crania, depending
in some cases on hypertrophy of the brain, or
more frequently on chronic hydrocephalus. In
these exceptional cases the palates were as
widely in excess, as in others they are less than
the normal width. One result, or rather one
accompaniment, of this narrowing is the in-
ordinate vaulting of the palate, which assumes
a roof-like form. The vaulting is not simply
apparent from the approximation of the teeth
of the two sides, it is absolute — the line of junc-
tion between the palatal bones occupying a
higher plane. Often there is an antero-poste-
rior sulcus corresponding to the line of approxi-
mation of the two bones.

There is very frequently a deficiency in the
posterior part of the hard palate, from a want
of development of the palatal process of the
maxillary bone, as well as absence of the palatal
process of the palate bone. As a result of this
defect, the false palate hangs down abnormally,
and interferes with clear phonation. At an

MOUTH TO MENTAL DEVELOPMENT. 283

early period of my investigations I was prepared
to find a large number of cases of cleft palate.
This does not appear, however, to be a frequent
defect — not more, according to my statistics,
than 5 in 1000 cases. Bisection of the uvula
occurred 4 times in 1000, and absence of the
uvula twice. The cause of the frequent exces-
sive vaulting of the palate is not quite clear;
it may possibly arise, as has been suggested,
from arrest of development of the sphenoid
bone, or defective growth of the bone. It has
been attributed by one writer to a cause which
I think cannot be allowed, viz. sucking the
thumb. This gentleman attributes idiocy
entirely, or almost entirely, to " fruitless suck-
ing." The chain of events, according to his
theory, is this : — The fruitless sucking gives
rise to secretion of gastric juice in the stomach
when it has no physiological use, — that this
acts as an irritant on the intestinal mucous
membrane, giving rise to diarrhoea and dis-
turbed nutrition, eventuating in convulsions and
idiocy; and that the roofed palate I have
described is the physical result of the pressure
of the child's thumb against the palate. Banish
fruitless sucking, he says, and idiocy would be

284 EELATION OF THE TEETH AND

unknown. I believe this to be a tborougbly
mistaken notion. Idiots are not much more
prone to fruitless sucking than other children,
and I have examined the palates of several fruit-
less suckers among the sane without finding the
palatal defects I have described. I think it will
require no argument to prove that the defects
I have referred to are developmental defects, and
that they betoken a cause long anterior to the
time when sucking the thumb is practised, unless
that habit be an intra-uterine one. The theory
overlooks the whole bearing of hereditary influ-
ence, and of nervous shocks and physical illness
to the pregnant woman, as potent causes of
imbecility in the offspring, and negatives the
idea of the congenital nature of the ailment.

There is one practical point with reference
to the palatal defect which has some interest to
me. One of the greatest difliculties we have,
but one which, when overcome, brings the
greatest kudos, is the teaching an idiot or imbe-
cile to speak. We have to furnish him with a
vocabulary, to practise him in tongue gymnas-
tics, to build up for him a language, and to
lessen the mutiny of the muscles of his tongue.
When all this is in part accomplished, the

MOUTH TO MENTAL DEVELOPMENT. 285

arcTied roof of the palate is a great trouble.
Imperfect speech still remains. Can nothing
be done mechanically in this direction ? Can
the members of this Society tell us of any
success they have had by diminishing the palatal
cavity among the sane that may augur hope for
us with the insane ? Often cases are met with
where the palatal difficulty is just the hindrance
to an improved imbecile mixing with the world,
and taking his place with his fellows.

Among idiobs and imbeciles there is often
discovered a want of symmetry in the cranium.
The plan which I adopt of taking the shape
with a strip of lead shows this defect admirably,
and enables me to sketch the precise deformity
on paper. This want of symmetry also affects
the bones of the jaw, leading to a great differ-
ence between the two halves of the maxillary
bones. A very marked example of this kind
was seen with me a short time since by my
friend Mr. Ramsay, who advised the removal
of some teeth to make room for the movements
of the tongue. It was an excellent example
also of the obtuseness to pain which is common
among the feeble-minded. Often they are
anxious to have their teeth extracted, as if it

286 EELATION OF THE TEETH AND

were a personal favour ; tliey are flattered by
the attention, — rarely do they care for the pain
which is inflicted, — chloroform is for them a
superfluity.

A want of symmetry is occasionally noticed
in the palate when there is no very marked
absence of symmetry elsewhere.

I might also mention anomalies of the tonsils
and of the fauces, but these would have but little
interest to you.

The gums are extremely prone to recede from
the teeth, and to become tumid, as in the scor-
butic condition.

The masticatory process is always performed
with diflBculty. The carious condition of the
teeth is one cause of this, but it is principally
due to the imperfection with which any volun-
tary act is performed. The sense of taste is
obtuse, no medicine, however nauseous, is re-
fused, and without care many will eat with indif-
ference the most offensive garbage.

To sum up, we have in the condition of the
mouths of idiots important data for distinguish-
ing between idiocy of a congenital and that of
a non-congenital origin, and to base thereon
a prognosis as to relative improvement by

MOUTH TO MENTAL DEVELOPMENT. 287

treatment. They are, tlie tliickness of the
lower lip, the delay of dentition, premature
caries of the teeth, the irregularity of dentition,
the chronic inflammation of the gums and buccal
mucous membrane ; the height, angularity, and
want of symmetry of the palatal vault ; the long,
corrugated, and coarsely-papulated tongue, and
the hyper-secretion of saliva. Common to the
congenital and non-congenital cases we meet with
defect of mastication, a want of co-ordination
of the muscles of the tongue, and the slight
development of the faculty of speech.

I am anxious to hear from the members of
this Society their own experience with regard
to any feeble-minded patients that may have
come under their observation, and how far the
picture I have drawn from nature contrasts
with what they meet with in members of a
sane community. It is quite possible that
some of the characters I have noted may be
met with sometimes among those who are
doing their work in the world, and are among
the bread-winners of society. My own expe-
rience leads me to consider that they are ex-
ceptional cases. May not palatal deformities
be indicative of a slightly degenerative process ?

288 EELATION OF THE TEETH, ETC.

When investigating cretinism in the valleys of
Piedmont, one is struck with the very gradual
deterioration of the race. Some of the typical
features of cretinism are met with among the
grandparents, and we have been able to trace
the increased degenerative stages through the
children to the effete grandchildren.

I have often had a wish to measure and
note the condition of the mouths of some of
the progenitors of my patients, and trace — as
I believe in some instances one could trace
— the gradual deterioration of the species till
it culminated in congenital imbecility.

That is just the link that I have not been
able to forge. I know no men more likely
than those I have the honour to address to-
night, to be able to fill up, from their experience,
the shortcomings of my own.

THE

OESTETEICAL ASPECTS OF IDIOCY.

' Trans. Obstet. Soc.,' 1876.

If one regards tlie large number of children
in our community wlio grow up with defective
mental power, children who, although not all
fairly to be ranked among decided idiots, yet
have such lesion of the faculties of perception
and reasoning as to bring them under the cate-
gory of the feeble-minded, and if one has
reference to the terrible anxieties such children
entail on their parents, and the burden they
often are to the struggling members of our race,
one cannot fail to be impressed with the import-
ance of anything connected with the circum-
stances of such a condition.

I had therefore no diflBculty in responding
to an invitation to bring before this Society
some of the opinions which have been im-

19

290 OBSTETRICAL ASPECTS OF IDIOCY.

pressed upon me, having relation to facts
which come under the immediate regard of
gentlemen practising the obstetrical ^^branch of
our profession.

The data on which these remarks are based
have been collected over a space of more than
eighteen years, and relate to two thousand
children who during that time have come under
my observation, and about whom I have been
able to gather information. They have been
collected with great care and with an anxious
desire to exclude all doubtful matter.

One very interesting and important point
suggested by my inquiries is that of primogeni-
ture. We know how much our political system
hangs on the laws of primogeniture, how the
first-born inherits property and inherits too the
power to rule over his fellows, and how much
our whole social structure is built thereon.
Nevertheless, the result of my statistics shows
that no less than 24 per cent, of all the
idiot children I have seen are primiparous
ofi'spring. How many primiparse there are
who, although not coming under the category
of idiots are yet somewhat incapable, my
statistics, of course, do not reveal.

OBSTETRICAL ASPECTS OF IDIOCY. 291

It will be obvious, however, tliat before any-
real value can be assigned to this statement it
will be necessary to inquire into the average
number of children belonging to these fami-
lies. This I have been at great pains to ascer-
tain, and I find that up to the time I had "been
consulted in each case 6'91, or nearly seven,
was the average number of living children
born to the parents who have had an idiot
child. Fourteen per cent, were second born, 9
per cent, fourth, 5 per cent, fifth, 7 per cent,
sixth, 10 per cent, seventh, 2 per cent, eighth,
9 per cent, ninth, 2 per cent, tenth, 2 per cent,
eleventh, 1 per cent, twelfth, 3 per cent, thir-
teenth, and 1 per cent, fourteenth. The
question naturally presents itself as to what
should give this undue preponderance of idiocy
to primiparse. I have no doubt that it may be
largely attributed to the exalted emotional life
of the mother ; her life is one of exaggerated
hopes and fears ; she is prone to live in an
unnaturally expectant atmosphere. She is
going through an experience altogether new,
with untried responsibilities both social and
domestic. She is more than usually responsive
to external impressions and influences, cer-

292 OBSTETEICAL ASPECTS OP IDIOOr.

tainly more to subjective feelings and wliims.
But, as I have elsewhere observed, it would
betoken a narrow view of the matter if we
restricted our attention to the emotional life
of the mother and kept out of sight the emo-
tional tendencies of the father. No one who
has seen much of private practice is unaware
how much men are frequently influenced by
the responsibilities of the matrimonial state,
how the doubts as to their own virility, of their
being able to make a position in the world
after having given hostages to fortune, the
disturbing elements of a new social position
both with regard to their immediate circle of
friends and to the new relationships formed.
All these and some others are perturbing in-
fluences to many men, and while, therefore,
the emotional life of the incubating mother is
an important element, the emotional tendencies
of the procreating father must be regarded too
as a cause of the increased frequency of primi-
parous idiots.

But there is another cause which will natu-
rally occur to the Fellows of this Society as ob-
stetricians. I refer to the increased difficulties
of parturition. No one can have regard to the

OBSTETETOAL ASPECTS OE IDIOCY. 293

smallness of tlie maternal passages, to their
undilated characterj to the rigidity of the peri-
naeum, and to the tediousness of the labour,
■without being impressed with the influence
they must have in interfering with the integrity
of the cranial contents, and to their inducing
a condition perilous to the future mental
health of the little one. They are conditions
which frequently give rise to instrumental in-
terference, but above all to a state of suspended
animation which in my opinion it should be
the earnest desire of the obstetrician to avoid.

I think it cannot fail to strike the Fellows of
the Society as a very important fact that no
fewer than 20 per cent, of the idiots of my
investigation were born with well-marked sym-
ptoms of suspended animation — symptoms
which required judicious and strenuous efforts
to overcome in order to effect resuscitation.
Moreover, it is specially interesting that while,
as we have said, 24 per cent, of idiots gene-
rally are primiparous, as many as 40 per cent,
of resuscitated idiots come under this category.
Clearly, then, suspended animation is a condi-
tion as far as possible to be avoided by the
practical obstetrician.

294 OBSTETRICAL ASPECTS OF IDIOCY.

Bearing on this part of the subject is the
question of instrumental interference. I have
made a careful inquiry on this subject over a
very large area, and with the expectation I
should find a large amount of idiocy to be the
result of " meddlesome midwifery," but I am
bound to say that my statistics falsify my anti-
cipations, and redound to the care with which
instruments are employed in parturition. I
find from an examination of all my cases about
which positive information could be obtained
that in only 3 per cent, were the forceps em-
ployed. In every case, however, where they
had been employed the friends of the child
believed that the instrument alone was the
cause of the disaster, while in nearly every
case I could discover quite suflBcient to account
for the mental defect in the neurotic history of
the progenitors. In a very few cases, only a
small fractional percentage, could I arrive at
the conclusion that the use of the forceps was
the principal cause of the calamity.

I find in a very large number of my cases
that the labour was stated to be unusually
tedious and prolonged. Dr. Playfair has
shown that the employment of the forceps

OBSTETETOAL ASPECTS OP IDIOCY. 295

does not interfere with the viability of the off-
spring, and that a prolonged labour is more
compromising to the life-prospects of the child
than a judicious and timely application of the
forceps. Certainly my statistics make clear to
me, contrary to what some years since was
advanced by Dr. Arthur Mitchell, and in har-
mony with Dr. Ramsbotham's experience, that
the use of the forceps is not an important
factor in the production of brain disease.
When, however, it is borne in mind how fre-
quent is the association of suspended anima-
tion with idiocy, it cannot, I think, be too
strongly enforced that the mental integrity of
the child is more likely to be compromised by
a prolonged pressure in the maternal passages
than by skilled employment of artificial assist-
ance. The accoucheur who postpones instru-
mental help often does so at the risk of terrible
consequences to the nervous system of the
little one he is solicitous to protect.

I have collected a good deal of information
as to the influence of twin births. There is a
general prejudice that the individuals of twin
births are not strong physically. Mr. Galton
has been collecting materials on this and

296 OBSTETRICAL ASPECTS OF IDIOCY.

cognate subjects, but I am not aware of
bis results. Taking my last tbousand cases,
only 2 per cent, were twins, while, singularly
enough, the same thousand show that in 2 per
cent, of the cases the mothers had given birth
to twins who were not afflicted in any way.
This would appear to indicate that the exist-
ence of twins does exercise some prejudicial
influence, seeing that among one thousand
mothers who have borne an idiot child, where
they have happened to be twins, no fewer than
a quarter of them were idiots.

A very potential cause in the production of
idiocy is the physical health of the mother
during gestation. In 20 per cent, of my cases
there was a history of marked physical dis-
turbance. In 4 per cent, there was a history
of serious falls — falls which were followed by
alarming uterine hsemorrhage. In 6 per cent,
there was an account of prolonged ill health,
and in no fewer than 10 per cent, was there a
history of sickness — cases in which the vomit-
ing had been marked and persistent, and had
given rise to anxiety on account thereof.
I feel quite sure that sickness during pregnancy
is an important producer of idiocy and is a

OBSTETEICAL ASPECTS OF TDIOOT. 297

symptom whicii, from tliis grave aspect of it,
claims the earliest attention of the obstetrician.
It will be readily understood that any cause
which would render the mother anaemic would
be a source of peril to the mental health of the
child.

From what I have already said it will have
been gathered that I lay great stress on the
emotional life of the child-bearing woman as a
potential cause of idiocy. I cannot, however,
attach greater importance to this aspect of the
subject than it deserves. It is one of most
serious importance and bespeaks one's careful
regard. In no fewer than in 32 per cent, of
my cases was there a well-founded history of
great physical disturbance in the mother by
fright, intense anxiety, or great emotional
excitement. They were all cases in which a
strong impression had been made on the mind.
In a large number of instances the fright was
attended by syncope. They were cases of
fright arising from threatened outrage to the
person, or where they had seen their own
children in great peril or killed, or where
intense anxiety had existed in consequence
of the fatal illness of their husband or the loss

298 OBSTETRTOAL ASPECTS OF IDIOCY.

of several of tlaeir children. No doubt they
were troubles in many cases which might have
been borne with equanimity by a philosopher,
but the mothers possibly were more than
usually responsive, and with an unstable equi-
librium required only the stimulus of fear op
anxiety to exercise a morbid influence on the
development of their children. 'No doubt the
emotional tendency of the mother, as depend-
ing on the same neurosis, may be regarded as
a cause, but the actively potential cause in all
the cases I have referred to was mainly the
undue response to some external impression.
The lesson to be gathered from such data is
a very important one, viz. to maintain the
child-beariug woman in the most equable state,
to shield her as much as possible from all
causes whicb would disturb unduly her
emotional life, and to maintain in her tliat
hopeful spirit and placid calm which is so much
to be desired both for the woman herself as well
as for the infant she is incubating. These
data teacb us how important it is that for
women generally the emotions should not be
cultivated at the sacrifice of their judgment
and self-control.

OBSTETEIOAL ASPECTS OF IBIOOT. 299

The relation of sex to idiocy presents some
matters of interest ; there is a marked prepon-
derance in the number of male over femaJe
idiots, The proportion among the two
thousand I have noted stands in the ratio of
2*1 to '9, or rather more than twice as many
male as female. It is, I think, a very fair
conclusion to arrive at that one very important
factor is the increased dimension of the male
over the female infantile cranium. This would
be likely to give rise to prolonged and difficult
parturition, to that continued pressure and that
suspended animation which I regard as so
disastrous to the cerebral functions. Another
reason is the greater tendency, according to my
notes, to infantile convulsions among males who
have become idiots than among females who
have become idiots, a circumstance which gives
rise to a larger amount of what I call accidental
idiocy among males. These statistics are,
moreover, in harmony with what we know of
the greater viability of female over male
children. The question of sex opens up many
interesting problems in relation to idiocy. I
can only here intimate that where the origin is
purely of a neurotic character my notes show

300 OBSTETRICAL ASPECTS OE IDIOCY.

that when the neurosis is paternal the male
progeny are liable to suffer and the female to
escape ; where, on the contrary, the neurosis
is maternal the female progeny are likely to
bear the stress.

I have been at some pains to ascertain
whether there is any relation between the
administration of ergot of rye and idiocy. I
have found, however, the answers so vague and
the knowledge of my informants so uncertain
that it has proved quite hopeless to arrive at
any results which would have a scientific basis.
Often the mothers have imagined that ergot
had been used when there had been no such
administration, and it is obvious that in many
cases the medicine may have been taken with-
out the mother being conscious that any drug
had been made use of.

The diagnosis and prognosis of idiocy are
both matters which perforce fall to the lot of
the obstetrician, and it is of no small import-
ance that he should have definite bases on
which to form and give an opinion. An error
in diagnosis would lead in all probability to
unpleasant lessening of professional confi-
dence.

OBSTETRICAL ASPECTS OF IDIOCY. 301

The earliest observations, on the part of those
in attendance on the child, of defect of sight,
of unusual fretfulness or peculiarity as to
taking food, should lead to very careful investi-
gation of the structural formation of the child.

In cases which have a congenital origin
you may find very early physical signs of
serious trouble. The cranium must be ex-
amined as to its configuration, giving special
heed to want of symmetry, to extreme dolico-
cephalism, to extreme brachycephalism, to
rapid shelving at the occipital region, to the
condition of the sutures, their premature or
deferred synostosis, and especially to the
frontal region which often displays the medio-
frontal suture still existing, whereas there
should have been complete coalescence of the
two halves of the frontal bone during intra-
uterine life.

Examination of the ocular media and retina
will remove the notion of blindness, and
indicate that the defect in taking notice of
external objects is rather one of cerebral than
optical defect. The presence of strabismus
should be noted, and the integument about the
eye should be examined especially for semi-

302 OBSTETRICAL ASPECTS OF IDIOCY.

lunar folds of skin at the inner canthus — folds
which are more frequently present in feeble-
minded children than in others, and which I
have been accustomed to describe as epicanthic
folds. They are according to my experience
marks of developmental degeneracy, and
should be looked for. The position of the
eyes is worthy of note, whether the inner
canthi are too nearly approximated, as met with
in microcephalic or scaphocephalic idiots, or
too widely separated, as obtains in macro-
cephalic and hydrocephalic idiots. Observation
should also be made as to any obhque position
of the eyes as well as their wide separation,
such as is met with in that ethnical variety
which I have elsewhere described as Mongolian
idiocy, a variety of great clinical as well as
biological interest, showing that degenerative
causes may and often do remove children into
a different ethnic type from that of their
progenitors. Particular observation should be
made as to that peculiar oscillation of the balls
called nystagmus, which is very frequently met
with in children of the feeble-minded class.

The appearance of the external ear should
be noticed, the condition of the pinna, the

OBSTETEIOAL ASPECTS OF IDIOCY. 303

absence of a helix, and whether the lobule be
absent. Observation should also be made as
to the seat of implantation of the ear, which in
idiots is usually placed further back in relation
to the head and face than in normal children.
No feature is more worthy of regard than the
configuration and position of the external ear.

The mouth should be examined as to its
palate, whether it be arched or Grothic-shaped ;
the tongue, whether it be too large, rugous,
fissured, and with its papillae enlarged ; the
jaw, as to the angle formed by the ascending
and horizontal rami, which in idiots is more
obtuse than usual.

Examination should be made of the surface
of the body as to the condition of the skin —
noting whether it has a lax and soddened
appearance, especially on the extremities, and
whether there be any defective coalescence at
the bottom of the spine. The muscular system
should be examined, special observation being
made as to the existence of any automatic
movements, contractures, or spastic rigidity.
In early childhood as well as in more advanced
life too much attention cannot be given to
these physical signs of cerebral disease. They

304 OBSTETRICAL ASPECTS OP IDIOCY. •

are, many of them, the marks of that kind
of idiocy which is inherited or congenital in
its origin, of that kind which is so often met
with as the outcome of a gradually degenerating
race.

Idiocy, however, is not always strictly con-
yenital ; in a large number of cases it is
acquired or accidental. This includes those
cases which occur from inflammation, often of
a slow and insidious character, of the meninges
whereby products are thrown out which after-
wards interfere with the nutritive supply to
the encephalon. It includes also the recoveries,
although very rare, from tubercular meningitis,
from infantile convulsions, and from acute
diseases of various kinds, also those arising
from traumatic injury as well as those where
narcotics have been injudiciously and probably
furtively given.

It is of great importance to be able to
differentiate these accidental cases from the
congenital ones, and this can only be done by
having regard to the physical diagnosis I have
before referred to. Often the friends of the
children refer the origin of the disaster to a
careless nurse who has let the child fall, to

OBSTETRICAL ASPECTS OE IDIOCY. 305

some remembered fright, or to an accoucheur
who has used instruments unadvisedly ; but a
reference to the physical condition of the child
may tell one that the cause was long antecedent
to the one suggested, and that far back in
intra-uterine life, or possibly before, in the
history of the progenitors, must the real cause
be traced.

Not only is physical examination important
in a diagnostic point of view; it is of no less
value, as we shall see, in prognosis. What
is to be the future of our child ? is a ques-
tion which will be put with more or less
earnestness, usually with an earnestness from
which there is no escape, and the reply will be
treasured for years to come. I j&nd that a large
number of replies are given, apparently based
on some sort of belief in periodic leaps. The
favourite epoch is seven years. The friends
are often lulled into a false security under the
notion that at seven, fourteen, or twenty-one
years of age all will come right. I know
nothing of such cataclysmal improvements.
The misfortune is that such opinions prevent
all active means being employed, and when the
longed-for time arrives it is found that precious

20

306 OBSTETRICAL ASPECTS OP IDIOCY.

opportunities have been lost, that with in-
creased physical development there has come a
stronger will, more resolute disobedience, and
an absence of intellectual and moral growth
which proper training might have effected.

But a no less fallacious opinion is often
based on the good looks of the patient. The
child probably does not speak at the proper
time, rolls its head in a rhythmical way, looks
into space, or makes monotonous noises with its
lips. " Oh !" it is often said, " have no anxiety,
all will come right ; he is so bright-looking, so
comely, he has no deformity of head, no lesion
of limb." The friends have no difficulty in
falling in with such a doctrine, and they await
in full reliance the future which is predicated,
but it is a future which never comes. It is
experience alone that tells one that the pro-
gnosis in such a case is far less hopeful than
in the case of one whose misplaced eyes, ill-
shaped cranium, and distorted face gives ready
indication of his feeble mind.

The case we have been considering is one of
accidental origin. Something since birth has
given rise to the disaster and has left no trace
on his exterior. With such an one we are able

OBSTETRICAL ASPECTS OF IDIOCY. 307

to predict much less response to training than
in the case of one whose defects have had an
origin anterior to birth. It may be taken as a
rule which has but few exceptions, that con-
genital idiocy is more amenable to training
than post-congenital, that, in fact, it is more
hopeful to have to do with an ill-developed than
with a damaged brain, and having regard to
what I have laid down as to the physical
signs and configuration of congenital idiocy,
that the prognosis is, contrary to what is so
often thought, inversely as the child is comely,
fair to look upon, and winsome.

It will be readily conceived how many
interesting points of departure are suggested
by the topics I have touched on. I have
endeavoured, however, not to wander into
simply philosophical paths, but to confine
myself to what I considered had most direct
bearing on " the obstetrical aspect of idiocy."

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